a formative survey of the private health sector in the...

A Formative Survey of the Private Health Sector in the Context of the Working Poor.

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Prepared for Department for International Development (DFID)

A Formative Survey of the Private Health Sector in the Context of the Working Poor.

Private Sector Innovation Programme for Health (PSP4H)

A Formative Survey of the Private Health Sector in the Context of the Working Poor. Insert project name

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Contact Information

Cardno Emerging Markets (UK) Ltd

Oxford House, Oxford Road

Thame

Oxon

UK

OX9 2AH

Telephone: +44 1844 216500

http://www.cardno.com/

Document Information

Prepared for Department for

International Development

(DFID)

Project Name Private Sector Innovation

Programme for Health

(PSP4H)

Date 31st March 2014 (Revised

27th June 2014)

http://www.psp4h.com

Implemented by a Cardno Emerging Markets consortium:

With partners:

Funded by the UK Government:


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List of Acronyms

DFID

FGD

GDP

IDI

KES

KHPG

Department for International Development

Focus Group Discussions

Gross Domestic Product

In-depth Interview

Kenya shilling

Kenya Health Policy Framework

KNSB

KAIS

KDHS

MDG

MOH

M4P

Kenya National Statistics Bureau

Kenya AIDS Indicator Survey

Kenya Demographic and Health Survey

Millennium Development Goals

Ministry of Health

Making Markets work for the Poor

NGOs

NHIF

NHSSP

OOP

PPI

PSP

PSP4H

PPP

Non-government organizations

National Health Insurance Fund

National Health Strategic Plan

Out of pocket

Progress Out of Poverty Index

Private sector providers

Private Sector Innovations Programme for Health

Public private partnership

VfM Value for money


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Recommended Citation

Private Sector Innovation Programme for Health (PSP4H). 2014. A Formative Survey of the Private Health

Sector in Kenya in the Context of the Working Poor. Nairobi: PSP4H


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Foreword

The Private Sector Innovation Programme for Health (PSP4H) is a cutting-edge programme located at the

intersection of private sector development and health care. Funded by DFID and charged with exploring how

a market systems approach might be applied to pro-poor health interventions, PSP4H began in late 2013 by

researching the supply and demand sides of the health care market in Kenya. This research took two forms

– secondary research consolidating the existing body of knowledge, and primary research discovering new

knowledge. The outcome of the primary research has been highly anticipated by the Kenyan health care

community; this report represents PSP4H’s initial publication of knowledge based on new data.

During the period October 2013 through March 2014, PSP4H researchers travelled to 12 Kenyan counties

and conducted focus group discussions with 518 health consumers and service providers to understand the

health-seeking behaviour of the working poor. We held in-depth interviews with 99 key individuals in these 12

counties to explore the supply side of the market as well as the regulatory environment. Finally, we held

open forums with 83 attendees in Nairobi, Mombasa and Kisumu to identify private sector opportunities,

market constraints, and areas where the poor are underserved. The findings of these discussions and

interviews as reported in this document are quite enlightening.

The working poor in Kenya are active market players, consumers with needs to be served in the marketplace

rather than passive beneficiaries. They currently pay out-of-pocket for health care and express a preference

for private providers for reasons of both service and quality. On the other hand, private sector providers

perceive that most poor Kenyans are unwilling and unable to pay for their services. This mismatch of

perceptions and reality underscores a potentially vast (and currently underserved) market for well-targeted

private sector health care initiatives.

PSP4H research highlights new data that should be of great interest to private sector health care investors

as well as public sector policy makers: for example, it answers the question of why the poor prefer the private

sector, and it identifies neglected illnesses for the poor.

As PSP4H proceeds to test business models that better serve Kenya’s poor health consumers, we trust that

our research will help inform the business community about the potential of pro-poor health markets and

stimulate not only more attention to these markets, but also more specific investments that serve the poor.

Ron Ashkin

Team Leader

PSP4H

Nairobi

February 2014


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Preface and Acknowledgement

PSP4H would like to acknowledge the contribution of the following in the realization of this report:

DFID for funding PSP4H; The Centre for Population and Health Research Management, under the

leadership of Rebecca Njue and Timothy Abuya, who contributed to the fieldwork, data analysis and report

writing; The PSP4H team – Ron Ashkin, Chris Masila, Salome Wawire, Dorothy Mbuvi, Barbara O’Hanlon,

Veronica Musembi, Pamela Godia, Ambrose Nyangao, Rachel Gikanga and Joyce Kyalo; and all the

participants in the study, whose insights form the basis of this report.


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Executive Summary

Background

The Private Sector Innovation Programme for Health (PSP4H) is a DFID-funded research programme

implemented by Cardno Emerging Markets and consortium partners. The programme utilizes market

systems approach to strengthen for-profit health sector’s capacity to reach the poor, and ensure that poor

people get better value for the money they spend on health in the private sector. Over the years, the private

for-profit health market has been relatively neglected by government and development partners. There is

little reliable information about the dynamics of the private health care market in many developing country

settings. Additionally, there is little information on how best to intervene in the private health care market to

benefit poor segments of the population. A number of initiatives have been developed through the support of

the United States Agency for International Development (USAID) and International Finance Corporation

(IFC) to support some analysis of the formal for profit sector and initiate policy dialogues primarily involving

private doctors. However there is paucity of approaches and initiatives to support for- profit formal sector that

provides services to the poor. In order to plan affective intervention, PSP4H commissioned an action-

research to synthesize existing information and gather new knowledge about pro poor private sector markets

to improve access for poor people. The overall programme objectives include:

> Assessing and defining who are the poor in Kenya and to better understand their provider preferences,

their health-seeking behaviour, and their willingness and ability to pay for certain health services and

products.

> Exploring under which circumstances the private health sector delivers health services and products to

lower income groups, determining if these services and products are of quality and are affordable, and

concluding if the private health sector services and products actually reach the poor.

> Assessing the Kenyan health market and sub-sectors to identify and pilot appropriate pro-poor

interventions by the private health sector and to conduct action research to establish if the private health

sector can deliver quality, affordable health services that reach the poor.

> Sharing the lessons learned from the different pro-poor health market interventions with Kenyan

stakeholders as well as international practitioners in public health working in developing countries.

To generate evidence for interventions to address inequities in accessing health care in the private sector

and to understand the health seeking behaviour and preferences for the poor, this study was designed to

answer the following questions:

> Who are the working poor in Kenya and what is their profile?

> What are the provider preferences for health care consumers within the PSP4H programme’s target

population?

> What are the health seeking behaviours of health care consumers within the PSP4H programme’s target

population?

Study Methods

The study adopted a cross sectional qualitative survey conducted in 12 selected Counties. A clustered

random sample for the counties was adopted with five large clusters namely: Western and Nyanza province

clusters, North and South Rift regions, North and South Coast regions, Nairobi and Central Kenya regions

and the lower and upper Eastern regions. The criteria for selecting the Counties was based on the under-

five mortality ratios, urban or rural setting, health spending budget for the counties, poverty index, presence

of health financing models targeting the poor, presence of high private sector and the presence of industrial

zones and large farms. On the basis of the above criteria, the following Counties were selected: Kisumu,

Busia, Nyamira, Nakuru, Narok, Garissa, Isiolo, Machakos, Kiambu, Nairobi, Mombasa and Kwale.


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The overall objective of the survey was to explore the definition of who are the poor in Kenya; assess the

working poor health provider preferences, their health-seeking behaviour and their willingness and ability to

pay for certain health services and products; and explore the challenges and opportunities available for

private health providers in the provision of health services and commodities to the poor.

A total of 63 FGDs were conducted with working poor (men and women), health workers in private sectors

and health workers working in retail pharmacy outlets. Sixty five in depth interviews were conducted with

county health managers, facility administrators and owners of private clinics and pharmacies.

In addition, three stakeholder forums were conducted in Nairobi, Mombasa and Kisumu, comprising of

private health care providers, investors, government officials and potential beneficiaries of the PSP4H

programme. The Forums had a total of 100 participants.

Key Findings What we learned about the poor

Who are the poor: There are a number of ways in which poverty is measured. It is multidimensional and

complex in nature and manifests itself in various forms making its definition difficult. Some authors argue that

no single definition can exhaustively capture all aspects of poverty, given its multidimensionality.

In this study we used a qualitative measurement tool to define the working poor (skilled or unskilled causal

and labourers). The tool was developed based on the existing approaches to defining poverty such as the

poverty index, Household Assets Assessment, Monetary/Income and Consumption Expenditure

Assessment, Progress out of Poverty, among others. The criteria used 12 domain areas for scoring on a

scale of 1-3 with the 1 being the poorest and three indicating the wealthy. The scoring indicators covered

housing, house space, rental status, source of water, fuel and cooking security, garbage collection,

sanitation, daily income of household, average number of meals per day, access to health services and type

of work. Those who scored the lowest were recruited in the study.

Health Seeking Behaviour: Health seeking behaviours differed by the illness reported. However, there was

a general pattern for one illness episode: seeking health care sequentially progresses from self-medication,

herbal/traditional care, public health facility to private health facility. In severe cases, the pattern skips the

public facility direct to the private facility. The costs to the poor include payment for services and

commodities at each stage. At the end of the illness episode, they pay more than they would have if they

went straight to a public or private health facility.

The main reason given by the working poor for seeking care in this pattern is lack of money to pay for

services in public and private facilities. Following the health-seeking patterns herein, the reality is that the

monetary cost of one illness episode is more than the cost of the same if care is directly sought at the public

and/or private health facility. Also, there are non-monetary costs such as increase in illness severity, length

of illness episode and economic losses due to extended illness.

Neglected Areas of service to the poor: Most of the working poor who participated in the study mentioned

that the services available to them were generally inaccessible in terms price, quality and physical location.

While there are some focus areas such as HIV/AIDS, malaria, child health and maternal health which are

relatively accessible, there are some areas that are grossly underserved. These are:

> Non-Communicable diseases such as cancer, diabetes and heart disease

> Dentistry

> Gerontological services (age-related illnesses)

> Respiratory infections

> Mental health

The main reason for these areas being underserved was given to be because the fields are highly

specialized and thus lack skilled professionals to provide the service at that level. Also, because of the

specialization in these services, the price tends to be too high for the working poor to afford.


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Ability and Willingness of the Working Poor to pay: The findings in this study show that the working poor

do regularly pay for health services and commodities in the private health sector. The willingness to pay is

contingent upon the perception that private sector services and commodities are of better quality and more

convenient than the public sector. Also, the working poor are willing to pay for services which are

specialized, such as diagnostic and pharmaceutical services, as well as disease-focused services such as

cancer screening and treatment. Also, the consumers indicated that they were willing to pay for services if

they were affordable. However, the health providers held the view that most consumers were unwilling and

unable to pay for private sector services.

What we learned about the private health sector

The focus group discussions with private providers revealed several challenges in delivering services. These

include:

> Enabling Environment. Policies and regulations present several barriers, impacting private providers’

ability to serve the poor. Key among them include: i) lack of policy clarity on private sector’s role and

contribution towards national priorities; ii) regulatory processes are “opaque” and cumbersome; iii)

uncertain MOH support and commitment to the private health sector; weak enforcement of Ministry

regulations and iv) limited incentives to serve the poor.

> Business Climate. Many private providers consider the Kenyan health market attractive for growth and

investment. And the MOH is increasingly receptive to working with the private health sector. Challenges

remain, however, including: i) high cost to set up a health business; ii) high cost of inputs (e.g. drugs,

equipment); iii) poor business and financial management skills. Several private providers also shared

that locating services in poor neighbourhoods brings unique management problems (e.g. security issues,

difficulty to recruit qualified staff, poor infrastructure).

> Market Competition. Private providers stated that competition is a big challenge and comes from multiple

sources: i) competition with informal providers; ii) competition with other private providers; and iii) unfair

competition with other private providers who receive donor subsidies.

> Lack of Information. There are persistent problems of poor communication and information sharing. A

key constraint is the exclusion of the private sector from MOH policy and planning processes. Other gaps

include: i) limited distribution of key government documents and strategies; ii) lack of consistent

communication on updates on regulations; and iii) few clinical training opportunities for the private sector.

Opportunities

With many African countries, such as Kenya, with worsening poverty and health outcomes, it seems ineffective to entirely charge the government with the responsibility of health care for all its citizens. The private sector in health has a role to play in improving health outcome especially among the poor. Table below describes various opportunities and approaches for working with Private Sector Providers PSPs) in the Kenyan market. Matrix of identified strategies to working with PSP for the poor (See next page). The qualitative research reinforces the growing knowledge of the private sector role in delivering services to the poor in Kenya. Although they face many challenges, the private sector is keenly interested in expanding their services to reach more clients – even the poor. Moreover, the research shows that in many cases, the private sector is the provider of choice, yet price makes access to private facilities and providers unattainable. The research revealed several opportunities to expand the private sector role while improving the quality and affordability of their services to benefit the poor. The qualitative study will guide the PSP4H programme as they enter into the design phase to develop partnerships with private providers that will reach the working poor in Kenya.


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Table 7. Matrix of identified strategies to working with PSP for the poor

Intervention objective

Interventions geared towards policy makers

Interventions geared towards providers

Enabling consumers and their representatives

Increase coverage of products and services with a public health benefit which are affordable for the poor

Strategy 1

Lower policy, regulatory and fiscal barriers

Remove barriers to private sector entry to market

Liberalize scopes of practice for key health cadre in private sector

Strategy 2

Recruit and network pharmacies into retail networks

Strategy 3

Recruit PSPs into an accredited network for specific health services with a public health benefit

Strategy 4

Contract with PSPs for packages of essential health care

Strategy 5

Market private sector services among priority target groups

Strategy 6

Introduce demand-side financing to remove economic barriers for priority target groups

Limit harmful practices and improve technical quality of care among PSPs

Strategy 7

Enact and enforce quality standards

Strengthen and enforce provider / facility licensing

Better integrate private sector in quality supervision

Strategy 8

Provide training supports and incentives to PSPs to conform to good practice norms

Strategy 9

Enact consumer protection law and raise awareness of consumer rights

Strategy 10

Increase consumer’s knowledge thru community education campaigns

Make PSP services more affordable

Strategy 11

Publish PSP prices

Encourage price minimums for priority services

Use insurance and contracting to influence prices

Strategy 12

Organize PSPs into group practices, insurance schemes and contracting

Strategy 13

Publish information to users on maximum permitted prices


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Table of Contents

List of Acronyms iii

Recommended Citation iv

Foreword v

Preface and Acknowledgement vi

Executive Summary vii

1 Introduction 13

1.1 Overview of Health Context 13

1.2 Working Poor’s Context on Health 15

1.3 Characteristics of the Private Health Sector 19

2 Methods 22

2.1 Objectives of the Study 22

2.2 Methodology 22

2.2.1 Focus groups and In-depth interviews 23

2.2.2 Description of Study Participants 25

2.2.3 Stakeholder Forums 26

2.3 Challenges in Data Collection 27

3 Findings 28

3.1 Who are the Poor in Kenya? 28

3.2 Working poor’s perspective on healthcare 29

3.2.1 Household decision making dynamics 29

3.2.2 Healthcare seeking patterns 30

3.2.3 Variance in health seeking behaviour 31

3.3 Provider Perspectives 32

3.4 Factors influencing access to health services. 32

3.5 Consumer ability and willingness to pay 33

3.5.1 What are the provider perspectives on consumers’ willingness to pay for health services? 33

3.6 Working poor’s preference for the Private Sector 34

4 Discussion 35

4.1 Overview of Private Health Sector 35

4.2 Private Sector Costs and Prices of Services. 35

4.3 Business Strategies to work with the poor 36

4.4 Private sector clientele 37

4.5 Common Medical Problems 37

4.6 Neglected Health Priorities in the Private Sector 39

4.7 Challenges Confronting Private Sector 39

4.8 The Poverty Penalty 41

5 Policy Recommendations 43

6 References 45


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7 Annex 1: Tools 48

8 Annex 2: Poverty screening tool 56


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1 Introduction

The following is a summary of the literature reviewed to guide the design of the qualitative research and

inform the analysis and recommendations.

1.1 Overview of Health Context

Kenya’s Economic Profile

Kenya is a low income East African country with an increasing population density, although the annual rate

of population growth has fallen since 1979, largely attributed to the expansion of family planning

programmes (KNBS 2010). Improvements in life expectancy after 1970 were reversed in the 1990s largely

due to HIV/AIDS. However, life expectancy has since improved, particularly as AIDS and infant mortality

rates have fallen due to health sector interventions (MOPHS 2009; NCPD 2000) (see table 1).

Table 1. Kenya demographic indicators, 1969-2009

Indicator 1969 1979 1989 1999 2009

Population (millions) 10.9 16.2 23.2 28.7 39.4

Inter-censal growth rate (*) 3.3 3.8 3.4 2.9 2.8

Density (population /km2) 19.0 27.0 37.0 49.0 67.7

% urban 9.9 15.1 18.1 19.4 21.0

Life Expectancy at birth 50 54 60 56.6 58.9 Source: (CBS 1970; 1981; 1989; 1999) (*) period between census is 10 years

In 2007, Kenya had a Gross Domestic Product (GDP) using Purchasing power parity (PPP) of US$57.9

billion or US$1542 per capita (UNDP 2007). The country had a period of increasing economic growth, with

GDP growth rising between 2000 and 2007 as the dividends of changes in government and favourable

global markets improved trade and international funding (Figure 1) (KNBS and ICF Macro 2010). GDP

growth declined dramatically in 2008, however, due to post election violence, increases in food prices, fuel

and fertilizers, and the effect of the global economic crisis (KNBS 2008). Inflation also increased markedly in

this period, only falling again in 2009. Kenya’s economic growth has also been associated with falling

poverty rates from 56% in 1997 to 46% in 2006. Urban poverty recorded the largest decline in that period

from 51.5% to 33.7% (KNBS, 2010).

Figure 1. Gross Domestic Product growth and inflation rates, 2000-2010

Source: (KNBS 2008; 2010; MoH 2007; MOMS 2008; 2010)

By 2007, Kenya had a Human poverty index of 29.5 9 (Figure 2) (UNDP 2007). There is debate about how

widely the benefits of economic growth have been distributed across the population. Kenya’s ‘Vision 2030’,

which sets its national vision, recognizes the need to close disparities between the rich and the poor and to

ensure that all Kenyans benefit from development programmes. While the fall in absolute poverty levels



suggests that economic growth has benefited poorer groups after 2000, it would be important to assess how

far the commitment in the national vision is being delivered.

Figure 2. Trends in Human Development Index, 1975-2007

0.42

0.44

0.46

0.48

0.5

0.52

0.54

0.56

1975 1980 1985 1990 1995 2000 2004 2005 2007

Hu

man

Develo

pm

en

t In

dex

Year

Source: (UNDP 1980; 1985; 2000; 2004; 2007)

Health Policy Context

The private sector for health in Kenya operates within a policy context shaped by internal and external

influences. A number of key policy documents have shaped the policy landscape including the Kenya Health

Policy Framework (KHPF) of 1994, the National Health Sector Strategic Plan (NHSSP) I: 1999-2004, the

NHSSP II: 2005–2010 amongst others (MoH 2005). The history of health sector reform policies can be

traced back to 1994 with the production of Kenya’s Health Sector Policy Framework Paper (GoK 1994). To

operationalise this document, the ministry of health (MoH) established the Kenya Health Policy Framework

Implementation Action Plan and the Health Sector Secretariat in 1996. In 1999, the MoH produced the

NHSSP I: 1999-2004, which covered a wide range of areas that needed to be strengthened to deliver better

health care to Kenyans. However, these plans were not effectively implemented, prompting the development

of the second five year Strategic Plan II aimed to revitalize the direction of the health sector (NHSSP II) (MoH

2005). The second National Health Sector Strategic Plan (NHSSP II) by the MoH aimed to reverse the

downward trends in health indicators observed during the years of the first strategic plan (NHSSP I, 1999–

2004), while applying the lessons learned and searching for innovative solutions.

More recently, the development of Kenya Health Policy Framework (KHPF) 1994-2010, launching of Vision

2030, enactment of the Constitution 2010, and activities that aims to fast track actions to achieve the

Millennium Development Goals (MDGs) by 2015 are the key milestones shaping the health policy

environment. Currently, the overall focus of health policy in Kenya is guided by Vision 2030, which aims to

‘transform Kenya into a globally competitive and prosperous country with a high quality of life by 2030’

through transformation into an industrialized middle income country (GoK 2011). The health sector policy is

grounded in the principles of the Constitution, specifically the right to health and the adoption of a devolved

system of Governance. Sessional Paper No 6 of 2012 on the Kenya Health Policy (2012-2030) outlines the

policy direction and the long term goals which the Country intends to achieve towards fulfilment of the

Constitution, Vision 2030 and global commitments such as the MDGs.

Health Care Expenditure

According to the 2009/10 National Health Accounts (NHA), the total health expenditure in Kenya was

estimated to be 5.4 percent of GDP at 2010 market prices, translating to per capita health spending of KSh

3,203 (US$42.4). This is a minor increase in per capita health spending from prior levels five years ago at

KSh2,861 (US$ 39) in 2005/06 (MoH 2010). The major sources of financing for the Kenyan health sector

include the government (representing the public sector budget allocation), external donors, individual



households and other private sector sources. The private sector – by individual out-of-pocket (OOP)

spending 0 is the largest contributor of health funds (36.7 percent), followed by external donors (34.5

percent) and the government (28.8 percent). Of the individual health payments, more than half went to shop-

keepers and for-profit service providers - some of the providers are qualified and licensed but many are not.

1.2 Working Poor’s Context on Health

Challenges in Defining the Poor

The literature on poverty and inequalities indicates that there is a great challenge in characterizing who “the

poor” are. Using a threshold definition (e.g. less than a dollar a day, or using a national poverty line) doesn’t

allow for regional variations and does not adjust for Purchasing Power Parity. A quintile analysis, involving

dividing the population into five equal groups (quintiles) based on an assessment of socioeconomic status

according to a standard of living index, shows that generally, the lower quintiles are more likely to have

poorer access to family planning services (Health Policy Briefs) and general medical care (KNBS and ICF

Macro 2010).

Economic barriers to the poor’s access to healthcare

The Kenya Household Health Expenditure and Utilisation Survey document the health care seeking

behaviour, health care service utilisation, and health expenditures, and can be used to give a snapshot of the

population’s choice patterns in seeking health care. The last survey (MoH & KNBS 2009) demonstrates that

outpatient health utilisation increased from 78% in 2003 to 84% in 2009. The increase in demand for

healthcare is attributable to the overall increase in income. The overall cost per capita of outpatient visits

was KSh 328 and 12% of those utilising outpatient services paid no fee. The wealthiest quintile spends 7

times that of the poorest quintile (Figure 3).

Figure 3. Annual per capita spending for outpatient care

Source: The Kenya Household Health Expenditure and Utilisation Survey 2009

When examining consumer preference, 57% received care at a government facilities, followed by 18% at

private facilities, 15% at a private chemist and at 6% at mission facilities.

Literature shows that payments for health services to contribute to inequitable access to health and

contribute towards household poverty. Studies cite that user fees and other out-of-pockets (OOPs) have

reduced use of health care services, particularly for poorest people, widening disparities in health care

uptake [27-30]. For example, socio-economic and geographic inequities in uptake of services were found to

be wider for inpatient than outpatient care due to the higher and more unaffordable costs of the latter

(Chuma et al. 2007; 2006).

Recognizing user fee’s negative impact on access to health, the Kenyan Ministry of Health policy on user

fees has evolved over time. The Ministry of Health (MOH) introduced user fees in Kenyan in 1989, but

suspended in 1990 due to problems with the hurried implementation; massive declines in utilisation of health

services; lack of quality improvements; and poor revenue collection (Collins et al. 1996; Mwabu 1995; 1995;



1986). In 1991, user fees were reintroduced in phases starting with tertiary and provincial hospitals, to health

centers and dispensaries. The MOH charged fees for individual services like drugs, injections, and laboratory

services and not consultations. The MOH exempted children under five and for specific services and

conditions such as immunization, management of tuberculosis, and fee waivers for poor people, although

the criteria for these waivers were not clear and may have relied on providers personal judgment.

Exemptions were reported to be cumbersome for both health workers and patients to implement (Collins et

al. 1996).

In July 2004, user fees at primary health care facilities (lowest level of care) were abolished and replaced

with a flat registration fee of Kenya shillings (KES) 10 and 20 for dispensaries and health centers

respectively- commonly known as the 10/20 policy, with the fall noted in the summary table in OOP spending

(MoH 2004). Children aged under five, poor people, specific health conditions like malaria and tuberculosis,

HIV/AIDS and other sexually transmitted infections, maternal health and delivery services were exempted

from paying the registration fees. An initial evaluation of the 10/20 policy reported high adherence to the

policy and an initial increase in utilization of 70%, levelling out to about 30% higher than prior to fee

reduction.

With the reduction of user fees, the revenue collected fell, with drug shortages and ‘overworked’ staff arising

due to the increased utilization. While the policy was popular among patients, it was not supported by health

workers (MoH 2005), and a later evaluation showed that adherence to the 10/20 policy fell, with charges

being raised for registration, injections, drugs, deliveries and laboratory services (Chuma et al. 2009).

To address this in 2005 a pilot project was introduced in Coast province, supported by DANIDA, to

compensate health centres and dispensaries for lost user fees. Under the project health facilities received

money through their bank accounts from the treasury without passing through the MOH (Opwora et al 2010).

While these measures were applied in the public sector, in the private sector out of pocket spending

accounted for 80% of expenditure on health in 2005, with per capita OOP spending of US$ 11.7 in 2003,

higher in urban than in rural areas, and with highest levels in Nairobi (US$ 18.8 in 2003 and the lowest in

Western province (US$ 3.3 in 2003) (Figure 4).

Figure 4. Out-of-pocket Expenditure 2003 and 2007 on Outpatient Visits

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

Per c

ap

ita e

xp

en

dit

ure i

n U

S$

2003 2007

Sources: (MoH 2004; MoPHS and MOMS 2009)

In 2006, government hospitals were allowed to charge women a delivery fee of US$ 6.5 for normal

deliveries. Mean OOP costs accounted for 17% of households’ monthly income on medical expenses for a

normal delivery, and double this for a complicated delivery. This level of OOP payments did not differ

significantly by socioeconomic status (Perkins et al. 2009). OOP payments impoverish about one million

Kenyan households annually (MOMS and MoPHS 2009), and about 7.7% of low income households incur

catastrophic health expenditure (Carrin et al. 2007). In July 2007, government abolished delivery fees (KSh

300-500) at dispensary and health centre level. While fee charges declined significantly, some fees or

informal charges were still charged to get services, and women had to purchase essential supplies like



gloves and cotton wool (Perkins et al. 2009). To address the lost revenue from fees and discourage these

additional charges, in December 2007, the Health Sector Services Fund (HSSF) was gazetted as an

extension of the pilot project (discussed previously), which sought to compensate facilities for revenue loss

following user fees reduction through direct transfers from the treasury (MOMS and MoPHS 2009).

OOP spending in the private for profit sector has continued to account for high levels of private expenditure

on health, but has fallen from 2003 levels to US$7.4 per capita in 2007, including in areas of highest

expenditure in Nairobi (US$15.9 in 2007) and Western province (US$3.0 in 2007 (MOMS and MoPHS 2009).

It is not clear what is responsible for this decline, but it suggest that people might have shifted their treatment

seeking patterns towards the public health sector. OOP spending remains an issue in at the hospital level,

and in the private for profit sector, and policy discussions on prepayment mechanisms and social health

insurance discussed later will be important input to providing financial risk protection for all Kenyans from

these charges.

Source: Kenya Demographic and Health Survey 2008-09

It is notable that almost none of the poor reported that they were covered by health insurance, while about

one quarter to one third of those in the richest fifth are covered.

Health seeking behaviour by the poor

Health seeking behaviour plays an instrumental role in determining consumer’s access and acceptability of

health services and products. Proper understanding of health seeking behaviour could reduce delay to

diagnosis, improve treatment compliance and improve health promotion strategies in many different

contexts. A review of the literature on health seeking behaviour show that the several factors determine

consumer behaviours and utilization of a health care system, public or private, formal or non-formal

(MacKian S 2003), the factors that influence the way people utilize health care can be broadly categorized

into five key groups – geographical, social, economic, cultural and organizational.

Thadeus and Maine the “three delays” model helps policymakers and programme managers better

understand how the wide range of factors can directly affect access to healthcare (Thadeus S and Maine D

1994). The three delays model organizes these factors along three action points in the process to seek and

receive healthcare: delay #1 in deciding to seek care, delay #2 in reaching the health facility and delay

#3 in receiving quality care once at the health facility.

Geographical Factors. One of the key factors contributing to greater burden of illness among the poor is

distance to a facility (Kiwanuka SN et al. 2008; Mwaniki PK, Kabiru EW, and Mbugua GG 2002; Buor D

2003; Duff P et al. 2010; Posse M et al. 2008; Kunihira NR et al. 2010; Futures Group Health Policy Initiative

2009). Access is a barrier for Kenyans, particularly those residing in rural areas. Nationally, according to the

2005-06 Kenya Integrated Household Budget Survey approximately eleven percent (11.3%) of Kenyans

travel one kilometre or less to reach a health facility, while about a half (48%) travel five kilometres or more.

Figure 5. Utilization of private providers



Rural-urban differentials show large disparities in distance to a health facility: only seven point four percent

(7.4%) of rural dwellers travel for one kilometre or less to reach a health facility compared to forty-nine

percent (49%) for the urban residents. In addition, more than a half of rural dwellers travel five or more

kilometres to reach a health facility, while only twelve percent (12%) of urban dwellers travel similar

distances (Central Bureau of Statistics Ministry of Planning and National Development 2005/06).

Socio-cultural Factors. Socio-cultural factors such local beliefs, women’s status and ethnicity have been

associated with delayed treatment. Local beliefs regarding aetiology of diseases strongly influence health-

seeking patterns. For instance, people are likely to consult traditional healers when they believe that an

illness is due to witchcraft. Previous studies on barriers to HIV treatment and care in Kenya found

considerable use of traditional and faith healers (Izugbara CO and Wekesa E 2011; Nagata JM et al. 2011;

Kiragu K et al. 2008). Research has shown that women’s autonomy is an important determinant of utilization

of health services (Chibwana AI et al. 2009). Kenyan men play a paramount role in determining the health

needs of a woman. The unwillingness of husbands to give money to facilitate their spouses to seek care or

lack of cooperation in decision making has been cited as a barrier to women’s access to health care services

(Essendi H, Mills S, and Fotso JC 2010; Tey NP and Lai SL 2013; Shaikh BT and Hatcher J 2005). Ethnicity

has also been found to be an important determinant of uptake of health care services. The Luhya and minor

ethnic groups in the urban slums were more likely than the Kikuyu to have delayed measles vaccination

(Ettarh RR, Mutua MK, and Kyobutungi C 2012). These findings are similar to previous research which

showed that ethnicity was key predictor of parental health seeking for childhood illnesses

(Teerawichitchainan B and Phillips JF 2007)

Socio-demographic Characteristics. Kenyan studies on determinants of utilization of maternal and child

health services have shown that factors such as educational level, age, place of residence, birth parity,

wealth status, exposure to media, knowledge of pregnancy risk factors were associated with use of health

facility delivery (Kenya National Bureau of Statistics (KNBS) and ICF Macro 2010; Mpembeni RNM et al.

2007). The most critical of the socio-demographic factor is a women’s education level, both formal education

and health knowledge. Education is strongly associated with improved maternal and child health outcomes

due to increased awareness of benefits of preventive and curative care. Increased knowledge prompts

health seeking behaviour as well as greater likelihood of adopting healthy practices. Maternal age is another

factor influencing health seeking behaviour. In a KNBS and IFC Macro Study, a mother’s age and the child’s

birth order are associated with a mother’s decision to seek healthcare or deliver at home. Births to older

women and those of higher birth order are more likely to occur with no assistance, compared with births to

younger women and those of lower birth order (Kenya National Bureau of Statistics (KNBS) and ICF Macro

2010).

Economic factors. Countless studies in Kenya and other developing countries highlight the significant

barrier that healthcare costs present to utilization of health services in both private and public sector.

According to the 2007 Kenya Household Health Expenditure Survey (KHHES), over a third of people who did

not seek care (38%) identified lack of money as the reason for not seeking care (KNBS and ICF Macro

2010). This is consistent with evidence from the 2008-09 KDHS which showed that women in Nairobi who

did not deliver in a facility were more likely to cite high cost as a factor than are women in other provinces

(Kenya National Bureau of Statistics (KNBS) and ICF Macro 2010). Data from the national health accounts

show that more than a third of the poor who were ill did not seek care compared to only 15% of the rich (Abt

Associates 2005).

Due to financial constraints, poor people resort to self-medication because they cannot afford to pay for

health care services. The 2005-06 Kenya Integrated Household Budget Survey showed that there is a higher

incidence of self-diagnosis and visiting of kiosks to purchase medicines, especially in rural areas (10%) than

in the urban (4%) areas. The proliferation of pharmacy shops and the common tendency to visit a hospital

only when faced with a serious illness are two reasons cited.

Indirect costs of seeking care creates barriers to utilizations. A study investigating barriers to HIV treatment

and care among children found that indirect costs were a major barrier to paediatric treatment although the

Kenyan government provides free ART. Clients bear additional costs including transport, consultation fees,

and medications to treat opportunistic infections and as a result respondents reported delaying or deferring

care for their children (Kiragu K et al. 2008). Lack of money to pay for transport or hire a vehicle to transport

a pregnant woman to a health facility is a commonly cited barrier to accessing referrals among poor urban

dwellers in Nairobi city (Essendi H, Mills S, and Fotso JC 2010).



Despite the direct and direct costs, an important percentage of low income households consistently seek

care in private facilities. Significant numbers of Kenyans receive health care in the private facility. Evidence

from the 2005-06 Kenya Integrated Household Budget Survey shows that among the former eight provinces,

forty-seven percent (47%) of the sick in Nairobi visited private health facilities (private hospitals/dispensaries

and clinics). In Coast (26%), Eastern (22%), and North Eastern (26%) provinces the proportion of the

population visiting dispensaries tend to be higher than the national average, while in Nyanza (20.5%) and

Western (22.4%) Provinces, pharmacist/chemist are the most preferred providers. At district level, in

Makueni, Bondo, Trans Nzoia, and Mt Elgon Districts about half of the population sought health care from a

private pharmacists/chemists and kiosks (Central Bureau of Statistics Ministry of Planning and National

Development 2005/06)

Organizational factors. How health services are organized, managed and delivered also influence health

seeking behaviour. Organizations factors include supplies, equipment, staffing, training and qualifications,

and quality of care (MacKian S 2003). Studies conducted among the urban poor in Kenya found that poorly

equipped health facilities in the slums and lack of essential drugs and supplies often discouraged women

from accessing health facility delivery care(Essendi H, Mills S, and Fotso JC 2010; Fotso JC and Mukiira C

2011; Izugbara CO, Kabiru CW, and Zulu EM 2009). Other studies state that many women are reluctant to

seek healthcare because of provider ill-treatment of poor women. When poor women present at facilities,

providers would reportedly abandon them, not listen to them, not ask them important questions. The

providers were also accused of being insensitive to the respondents' cultural beliefs especially during the

birthing process (Macha J et al. 2012; Kiragu K et al. 2008). A study conducted in Kenya, Tanzania and

Ghana shows that poor clients’ choice of a private facility over a public facility appears to be influenced by

the presence of a trained provider at all times (Agha S and Keating J 2009). In Kenya, close to a third (29%)

of providers was found to be absent in a public health facility. At the level of health centres public providers

were three times more likely to be absent than at private non-profit health centres (Martin GH and Pimhidzai

O July 2013). The 2010 KSPA survey found that the prospect of being attended to quickly was cited as

reason for seeking care in private facilities rather than in public facilities, which are associated with longer

lines and waiting times.

1.3 Characteristics of the Private Health Sector

Definition of the private health sector

The Kenyan private health sector is comprised of a diverse range of actors and is one of the largest and

most dynamic in Sub-Sahara Africa. The Ministry of Health now recognizes a pluralistic health system and

defines the private health sector to include “all players outside of the public or governmental sector”. In the

Kenyan context, the private sector includes both informal and formal health providers.

Figure 6 illustrates the wide range of groups and activities

performed by the private health sector in Kenya.

Informal Health Sector

There is scant information on the informal sector in

Kenya, as well as in developing countries more

generally, and much of what is known about Kenyan

informal health providers (IPs) is anecdotal. A recent

Systematic Review of international literature on IPs

identified the most common types of IPs, many of

which are operating in Kenya. The most common IPs in

Kenya include drug sellers; followed by village

doctors/traditional healers; followed by Traditional Birth

Attendants (TBAs), of which there are a significant

number. IPs generally practice poor preventive

medicine, rely on massage and herbal medicines, and

dispense products or services in discrete single dose

units (e.g., drug sellers). TBAs play multiple roles in

pre- and post- natal care that may or may not include

Figure 6. Composition of private sector



assisting with delivery.

Kenyans living in rural areas are more likely to obtain their health care from one of these types of IPs than

their urban counterparts. The Systematic Review found that IPs are frequently the provider of first choice,

and in some settings the only choice of health care provider, for rural poor households. In fact, depending

upon the country, disease, and measurement method, IPs have been shown to provide as much as 90

percent of the health care used by the rural poor. The three primary reasons that consumers, particularly

poor consumers, use IPs are convenience, affordability, and social and cultural norms. Researchers

estimate that IPs provide between nine and thirty three percent of the health care used by rural poor

Kenyans.

The Systematic Review also showed that quality of care varies widely among IPs and that IPs do not always

adhere to national clinical guidelines. Compared to providers in the formal sector, IPs have very limited

training and frequently lack capacity to provide basic curative services.

Formal Health Sector

Faith-Based Sector. Kenyan Faith-Based Organizations (FBOs) have a long history (over 100 years in

some cases) and long-standing relationships with the MOH. FBOs run almost one-fourth of all health

facilities in Kenya. There are three main faith-based umbrella associations that offer health services to rural

Kenyans, namely, Christian Health Association of Kenya (CHAK), Kenya Episcopal Conference (KEC), and

Supreme Council of Kenya Muslims (SUPKEM).

Non-Government Sector. Kenya has a thriving and active NGO health sector, in large part due to donor

support in response to pressing health priorities like the HIV/AIDS emergency, malaria, tuberculosis (TB) and

family planning (FP). Even though the Kenya Projects Organization (KENPRO) maintains an exhaustive list

of NGOs in Kenya, the exact number of Civil Society Organizations (CSOs) in Kenya working in health-

related activities is not available (HENNET, 2010). The Health NGOs Network Best Practices Technical

Working Group estimated the number to be greater than 6,000.

Commercial Sector. The private health sector is

dynamic and engaged in all aspects of the health

system – pharmaceutical manufacturing and drug

supply; health equipment; health training and

medical education; health financing; hospital

management and care; provision of sophisticated

laboratory and diagnostic services; and, provision of

health services.

The private sector owns, manages and operates

many healthcare facilities in Kenya. This section

provides an overview of health facilities and health

personnel owned, employed and managed by the

private health sector. It also presents MOH data

showing trends in private sector growth, composition and activities since 1999.

Private sector contribution Data compiled by the MOH shows that in 2013, the private sector owned a higher percentage of health facilities than the public sector: fifty-three percent compared to forty-seven percent, respectively (Figure 7). Within the private sector, the commercial sector owns almost three quarters of health facilities (seventy-two percent), followed by FBOs (twenty-two percent) and finally, NGOs (seven percent).

The majority of public facilities are health centres

and dispensaries, while the majority of private,

commercial facilities are clinics and dispensaries.

The public sector has the largest number of

TOTAL FACILITIES 9,448

Quick Facts on the Private Sector

The private sector owns and manages more than half of all the healthcare facilities in Kenya. Within the private sector, the commercial sector owns and operates three quarters of all private facilities. These facilities include primarily health centres and private consultation rooms. The FBO sector operates the majority of private sector hospitals, which are largely located in peri-urban and

rural areas.

Figure 7. Public-private mix of health infrastructure infrastructure



hospitals (fifty-six percent), followed by the for-profit sector (twenty-five percent) and the not-for-profit sector

(eighteen percent). The private for-profit sector dominates the nursing home segment (mainly small- to

medium-size private hospitals) and health clinics. The public sector and not-for-profit sectors own most of the

health centres and dispensaries.

In 2007/08, the majority of Kenyan health care professionals worked in the private sector, at either a for-profit

or a not-for-profit organization. Almost three quarters of doctors and almost two-thirds of nurses and clinical

officers worked in the private sector in 2007/08. This trend also held true in 2013.



2 Methods

2.1 Objectives of the Study

As seen in the literature, the private health sector plays a key role in providing health care to all Kenyans,

including the poor populations. The environment in which private health care providers operate is

characterized as unfavourable, owing to policy and regulatory processes that inhibit the provision of optimal

services to the clients, among other factors. Despite these observations, there is little reliable information

about the private sector market. Most studies tend to focus on the health issues rather than the dynamics of

the market itself. There is almost no experience in Kenya, and little globally on effective ways of intervening

in it to benefit poor people.

It is clear that a huge population in Kenya is affected by economic inequalities, which is also reflected in

access to health care. The poor are disadvantaged in this respect, as their access to quality health care is

affected by their limited resources to spend on health care. The poor themselves are not necessarily a

homogenous group and understanding the variability in this broad category may help programmes and

private health providers to focus interventions particular people and needs to maximize access to health

care. In order to understand the health seeking behaviour and preferences for the poor, one needs to

understand the contextual definition of the poor, examine their priorities and concerns about the sector. This

study sought to examine these issues within the context of devolved system of government in Kenya, and

answer the following questions:

The study was guided by the following research questions:



population?


population?

> Are the health care consumers within the PSP4H programme’s target population willing to pay for certain

health services and products and to what extent do they have the ability to pay for those products and

services?

2.2 Methodology

The study adopted a cross sectional qualitative survey in the 12 selected counties. A clustered random

sample for the counties was adopted with five large clusters namely: Western and Nyanza province clusters,

North and South Rift regions, North and South Coast Regions, Nairobi and Central Kenya regions and the

lower and upper eastern regions. The criteria for the selecting the counties was based on the under-five

mortality ratios, urban or rural setting, health spending budget per for the counties, poverty index, presence

of health financing models targeting the poor, presence of high private sector and the presence of industrial

zones and large farms. On the basis of the above criteria the following counties were selected: Kisumu,

Busia, Nyamira, Nakuru, Narok, Garissa, Isiolo, Machakos, Kiambu, Nairobi, Mombasa and Kwale counties.

The map below shows the Counties in which the study was done.



Figure 8. Map of Selected Counties for the Study

2.2.1 Focus groups and In-depth interviews

In each county, five focus group discussion (FGDs) and five in-depth interviews (IDIs) were conducted. The

sampling strategy and assumptions for all the FGD and IDIs are presented in Table 2. In depth interviews

were conducted with county health managers, facility administrators and owners of private clinics and

pharmacies to better understand the supply and demand side of health services to the poor with the counties

and explore the circumstances under which private health sector delivers health services and products to

lower income groups while assessing if these services and products are of good quality and affordable

(Tools in Annex 1). The selection of FGD participants was done through joint community mobilization that



was conducted by the research assistants and field supervisors with the assistance of the opinion leaders,

community elders and community health workers

Table 2. FGD Sampling Criteria FGD category Selection criteria Underlying assumptions

Women Below 25 years with young children or without Above 25 years with young children

Women influence mainly the health seeking behaviour of the family. The age however of the women influences their health seeking behaviour

Men Working in private/public sector in both formal and informal employments with young families

Make decision on how or when to seek health care

Health workers in private health clinics

Those who provide health services to the poor-large and small facilities

Provide services to the poor. It will help understand the context of the private market

Health workers working in retail pharmacy outlets

Those who provide health services to the poor-large and small facilities

Provide services to the port. It will help understand the context of the private market

The targeted working poor were screened for eligibility using a poverty grading tool (see Annex II). The

FGDs consisted of between eight to twelve participants with discussions lasting one to two hours. Each FGD

was conducted by two trained research assistants—a facilitator and a note-taker. Informed consent was

obtained from all participants before the discussions. The table below summarizes the number of

respondents for this study. A total of 574 respondents both for FGDs and IDI were interviewed (Table 3).

Table 3. Number of participants in the study Methods of data collection Distribution No. of

Respondents

Focused Group discussions With health workers Female Male

62 110

With working poor-men 71

With working poor-women Women over 25 years Below 25 years

166 100

Total FGD participants 509

In-depth interviews Health facility in charges 29

Pharmacy owners 22

County level policy makers 14

Total IDI participants 65

The discussions were tape-recorded in local languages and then transcribed into Word format and translated

to English. There was, however, no back-translation of the transcripts into the local languages. The

transcribed texts were then transferred to NVIVO 10 analysis software and analyzed by three researchers.

Following coding, a full list of themes was available for categorization within a hierarchical framework of main

and sub-themes (Annex III). The development of the thematic framework was based on an initial immersion

of the data from seven sites. These included in depth interviews as well as FGDs with various categories of

actors. The coding framework therefore utilized two main approaches: inductive approaches where two

researchers independently read through the transcripts and developed a set of themes that emanated from

the responses. The emerging themes were then linked with the guide that was used a priori. A tentative

thematic framework was developed for coding. The thematic framework was then systematically applied to

all the transcripts. Patterns and associations of the themes were identified and compared and contrasted

within and between the different groups of respondents. Among clients the focus of the guide was on health

care seeking patterns, decision making dynamics at household level, and cost of services. A total of 68

focused group discussions were held (Table 4).



Table 4. Type of focus group discussion by site Site Focus Group Discussions

Providers Beneficiaries

women < 25 years women >25 years men > 25 years

Busia 2 2 2 2

Garrisa 2 2 1 1

Isiolo 2 2 2 2

Kiambu 2 2 1 1

Kisumu 2 1 1 1

Kwale 2 1 1 1

Machakos 2 1 1 1

Mombasa 2 1 1 1

Nairobi 2 1 1 1

Nakuru 2 1 1 1

Narok 2 1 1 1

Nyamira 2 1 1 1

Total 24 16 14 14

2.2.2 Description of Study Participants

The Beneficiaries

Male beneficiaries Majority of the Male beneficiaries who participated in the FGDs had completed the O levels up to form 4. Only a few had a gone up to college and 32% had not completed primary education. Most of them were in small business in the jua kali sector, including masonry, farm labour, welding, among other activities. The mean age of the male participant males was 40 years. Female beneficiaries aged below 25yrs In the FGDs with women under 25years, majority of the participants had attained primary level education. A few had completed secondary education. It is also important to note that in Isiolo and Garisa majority had no formal education. Majority in Kwale and Mombasa had only attained primary level education, with only a few proceeding to secondary school. Majority of them were doing small businesses such as selling charcoal, vegetable and fruits, among other activities. The mean age for this group was 22years. Female beneficiaries aged above 25yrs Majority in this group had only attained primary school education level, though there was one who had attained university education and was working as an Mpesa Agent. Close to all the participants in Kwale and Mombasa had only attained primary level education while those in Isiolo and Garisa had not attained any formal education. The mean age for this group was 36 years. Health Care Providers A total of 94 health care providers participated in the study, 48 of the health care providers were female while 51 were male. Majority of the health providers were pharmacist, followed by nurses. The average age for the pharmacists who participated was 26years, nurses was 36yrs, clinical officers 28yrs, lab technicians 29yrs and CHW was 32yrs.



Table 5. Health Care Providers Interviewed

Gender Number Mean Age Education Occupation

F=18 M=25

43 26.34884 College=28 University=1 Pharmacy

F=25, M=8 33 36.06061

College Nurse

F=2 M=10

12 28.75 Diploma/ certificate -college

C.O

M=2 F=1

3 29

College Lab tech

F=2 M=1

3 32.66667

Certificate - college CHW

Total 94

2.2.3 Stakeholder Forums

In addition to the methods described above, three stakeholder forums were held, one each in Nairobi,

Mombasa and Kisumu. While the forum in Nairobi involved mostly stakeholders from Nairobi County, the

forum in Mombasa and Kisumu included participants from neighbouring Counties - such as Kwale and Kilifi

for Mombasa; and Siaya, Homabay, Kakamega and Vihiga for Kisumu. The government representatives in

Nairobi were from the National office of the MoH while those in Mombasa and Kisumu represented the

County governments.

The purpose of the events was to raise awareness to key stakeholders in the Kenyan health sector – both

public and private– on the PSP4H project, the M4P approach and to interest the private health sector to

participate in the programme. In addition, the forums were used as an opportunity to brainstorm on key

questions regarding the private health sector. The three main questions discussed at the forum were:

1. In what areas of health care are the working poor currently underserved?

2. What for-profit opportunities exist for the private sector to deliver health care to the working poor?

3. What problems and obstacles prevent the for-profit private sector from investing in health care for the

working poor?

The participants represented a wide range of project beneficiaries, organizations and individuals involved

with the Kenyan health sector including government officials from the MoH and finance, county health

representatives, private health sector leaders from umbrella organizations and private provider associations,

private sector investors, consumer organizations and donor agencies. Others included Kenya Health

Federation representatives, Kenya Association of Private Hospital representative, drug manufacturers and

suppliers, medical equipment suppliers, health insurance providers, private health care providers, health

project implementing agencies and health services consumers. The participants were identified through an

initial stakeholder identification process which included direct engagement using the existing networks,

through visits, emails and phone calls.

The forum agenda was divided into three key sessions. The first session covered introductions, including an

opening remark from the hosting county government representative such as the Governor or the director of

health. The second session was a presentation by the PSP4H project, providing background about the

Project and explaining the M4P concept. The third session involved breakout sessions where participants

were divided into three groups to address the above questions. Each group discussed one question from the

three, where they listed answers and later ranked the answers according to level of need and urgency. After

the breakout session, each group presented their views in a plenary session and further discussions were

held with the other members of the other two groups to crystallize the issues. A report for each forum is

appended to this report (Appendix 4).



2.3 Challenges in Data Collection

Time: Time is an important aspect for the working poor, majority are paid based on hours worked. To

accommodate the tight schedules of the study participants, all interviews were scheduled early in the

morning, at lunch time and late in the evening. Over 80% of the interviews and discussions were conducted

over lunch time and late in the evenings. Due to tight scheduling constraints, organizing a focused group

discussion to constitute more than 8 persons required longer mobilization time.

Availability of County Health Management Teams: The County Health Management Teams (CHMT) were

extremely busy setting up county health systems and thus setting up interviews with them difficult.

Fear of private investigation by sector players: Some of the private sector players were initially afraid that

the survey was investigating their processes, such as availability of licenses. However, proper consenting

and provision of all required information made it easy to set up interviews and FGDs with the private sector

players.

Limitations of the study: The findings of this report may be influenced by the following study limitations

including:

> Given that FGD participants were not randomly selected, their views may not be representative of the

opinions of the general population or of all working poor and health workers. It could be that those who

were approached and agreed to participate in the discussions had strong views about health care in

general and the private sector in particular. However, the fact that some of the qualitative findings—

especially views of the working poor and health workers - on the private sector are consistent with

findings from other studies in the country suggest that the bias is attributable to the nature of the sample

of participants in FGDs may have been minimal.

> FGD sessions may have been dominated by the opinions of a few thereby biasing the findings. However,

apart from being trained to undertake the study, the facilitators were individuals with basic training in

qualitative research and therefore understood the importance of ensuring that the discussions were

balanced.

> Societal attitudes and beliefs may have affected discussion around key areas such as HIV, STIs, and

other services that could have a social stigma. Due to stigma related to these issues, the extent of the

openness with which they were discussed in a FGD may have been compromised.

> Due to financial and time constraints, there was no back-translation of the transcripts to local languages

to determine if some meanings may have been lost in the process of translation to English.



3 Findings

Sections 3 and 4 offers the findings from the FGDs, IDIs and Open Forum. This section on the poor in

Kenya describes the poor and then delves into: i) how decision are made on health, ii) what influences when

and where the working poor seek healthcare, iii) the poor’s ability and willingness to pay and iv) underserved

health areas the poor need and want.

3.1 Who are the Poor in Kenya?

There are a number of ways in which poverty is measured. It is multidimensional and complex in nature and manifests itself in various forms making its definition difficult (Mariara and GK 2004). Some authors argue that no single definition can exhaustively capture all aspects of poverty. The welfare monitoring survey adopted the material well-being perception of poverty in which the poor are defined as those members of society who are unable to afford minimum basic human needs, comprised of food and non-food items. Although the definition may seem simple, there are several complications in determining the minimum requirements and the amounts of money necessary to meet these requirements (CBS 1997).

The Poverty Reduction Strategy also recognizes that poverty is multi-dimensional. It defines poverty to

include inadequacy of income and deprivation of basic needs and rights, and lack of access to productive

assets as well as to social infrastructure and markets. The PSP4H literature on poverty and health in Kenya

examined several methodologies including:

Household Assets Assessment is one of the approaches used to define the poor and is based on

household ownership of basic amenities such as the source of drinking water, type of sanitation facilities,

materials used for the floor of the house, property ownership and other characteristics that relate to a

household’s socioeconomic status. This approach is commonly used by national sample surveys such as the

Kenya Demographic and Health Survey (KDHS) and Kenya AIDS Indicator Survey (KAIS).

Monetary/Income and Consumption Expenditure Assessment. The proponents argue expenditure is a

better measure of poverty. However, household incomes are not easy to measure because they are not

always a true reflection of actual incomes. Household consumption expenditure is usually a more reliable

indicator. In the context of developing countries, it is often a challenge to accurately measure household

expenditures. The next Kenya health expenditure review is scheduled for release early 2014.

Progress Out of Poverty Index (PPI). The PPI is a poverty measurement comprising ten questions about a

household’s characteristics and asset ownership that are scored to compute the likelihood that the

household is living below the poverty line – or above by only a narrow margin. With the PPI, it is possible to

identify segments of the population that most likely to be poor or vulnerable to poverty. The recent KNBS

study on county income disparity uses PPI.

Using the qualitative approach based on various Participatory Poverty Assessments (PPAs) undertaken

since 1994, the people define, view and experience poverty in different ways. In the third PPA of 2001,

people mainly defined poverty as the inability to meet their basic needs. Poverty was associated with

features such as lack of land, unemployment, inability to feed oneself and one’s family, lack of proper

housing, poor health and inability to educate children and pay medical bills. Though different people and

communities defined poverty differently, poverty was invariably associated with the inability to meet/afford

certain basic needs. Given the multi-faceted nature of poverty, the nature and characteristics of poverty go

beyond income measures alone.

Certain aspects of poverty can be captured by quantitative surveys while others can be established by

qualitative studies. In Kenya the two approaches have been used to generate information on the magnitude,

extent, nature and characteristics of poverty. From both the qualitative and the quantitative poverty

assessments, the poor in Kenya tend to be clustered into certain social categories namely: the landless;

people with disabilities; female headed households; households headed by people without formal education;

Incidence of Poverty

In 2009, 45% of Kenya’s population live below the poverty line

Half of Kenya’s rural population live in poverty

One third of Kenya’s urban residents live below the poverty line



pastoralists in drought prone certain remote districts; unskilled and semi-skilled casual labourers; AIDS

orphans; street children and beggars; subsistence farmers urban dwellers and unemployed youth.

In this study we used qualitative measurement tool to define the working poor (skilled or unskilled causal and

labourers). The criteria used 12 domain areas for scoring on a scale of 1-3 with the 1 being the poorest and

three indicating the wealthy. The scoring document is presented as an annex. It covered housing, house

space, rental status, source of water, fuel and cooking security, garbage collection, sanitation, daily income

of household, average number of meals per day, access to health services and type of work. Those who

scored the lowest were recruited in the study.

3.2 Working poor’s perspective on healthcare

3.2.1 Household decision making dynamics

The final decision on where, when and how health care is sought is influenced by many factors, one of which is the dynamics experienced at the household level. The research revealed the factors influencing decision making and how they varied by geographic sites. In this study, it emerged that decisions on when and where to seek health care depended greatly on the financial cost of care. For illnesses that were considered severe, and thus financially burdensome, most discussants said the decision was made by the head of the household – who often was the man. The reason for this was that men were the financial providers and custodians in the household, and so decisions that required a significant amount of money was made by them. In a few instances where the woman was the financial provider, they made the decision, such as in female-headed households, households with mothers-in-law, or households where the female member was the main financial provider.

“From what I have seen there are different kind of households there are those that depend on the head of

the house that is the father or the husband.”

FGD, women, Nakuru

Among more traditional communities, health seeking decisions were made by male partners or male

household heads.

“In a household, the man is the head so he makes the final decision of where someone will be taken if sick,

whether to the pastor, hospital or the physician”

FGD-Machakos-Women

In less traditional settings, there are times when decisions are made depending on the urgency of seeking

care. For example, when the child is perceived to be in danger, in most cases the women will take the child

to the hospital and inform the male partner later. In Machakos for example, some respondents felt that,

depending on who is available at the time, anyone will make decision to seek care:

“Anybody close makes decision when one falls ill. I will take the initiative to take someone to hospital if he

falls sick while he is close to me.”

FGD-Machakos-Men

Also, decisions were made on the type of illness and the type of patient. For example, women were expected

to make decisions about care when a child is unwell, just as they are expected to decide on their own health

– especially if it is maternal health. One underlying factor for this is the fact that in the Kenyan system, these

services are available for free and/or subsidized in public and private facilities, and thus do not have financial

implications. The extract below demonstrates these differences.

“From what I have seen there are different kind of households there are those that depend on the head of

the house that is the father or the husband but in some family it’s the individual that”

FGD women –Nakuru

Decision making influenced by:

Financial cost of healthcare

Family structure and cultural perceptions of power at the household level

Perceived severity of the illness

Type of patient

Type of illness



Figure 9 illustrates two key avenues utilized during decision making process among communities in the

study.

3.2.2 Healthcare seeking patterns

Care seeking patterns appear to be closely linked with the common illnesses cited by study participants. A

general pattern emerged from the consumer interviews. Depending on the illness, a poor consumer first

resorts to self-medication, purchasing some form of medication at a drug shop or kiosk. If the “drug” did not

treat the condition, then the same consumer consults an informal provider because they cannot afford to pay

a private one or the fee at a public facility. Low quality and substandard medication received from the

informal provider often results in the consumer becoming more ill. As the illness progresses, the consumer

now enters into the formal health sector. At this point, the consumer first goes to a public facility. In severe

cases, the consumer will go directly to a private provider. Depending on the illness and cost of treatment, a

poor consumer will bounce between the public and private sectors to get successfully treated.

Figure 10. Client Health Seeking Behaviour

Generally the choice of the source of care at the chemist/pharmacy, private clinic or government facilities

ware mainly determined by;

Access to services: This is most described in the context of distance to the health facility and length of

waiting time for the services. It appears that the short waiting times at the private clinics and pharmacies is

the most important factor that attracts the working poor to seeking services within the private sector. Most of

the respondents explained that their jobs are mostly paid on the basis of hours worked and therefore the

short waiting time at the private clinics and pharmacies favoured them. Further there is a perceived notion

Figure 9. Decision making dynamics for care seeking at household level



that the private clinics have better quality of care- first it was reported that they often had the supplies and

commodities required, the providers in the private clinics had good communication skills and provided more

friendlier services compared to the public sector.

“We go to the county council hospital because they offer cheap services. On other occasions we go to the

private hospitals because in the government hospitals they only prescribe drugs for us to go and buy from the

chemists, the lines in the public are also quite long so we prefer borrowing money to take our relatives to

private hospitals for treatment-FGD Women Machakos

Quality of care: The quality of care was expressed as real or perceived but both had a significant influence

on the choice of health care by most study participants. These were expressed in terms of availability of

supplies and commodities and friendliness of services offered at the facility. The use of the

chemist/pharmacy was often associated with illnesses not considered serious and often they sought a

prescription from the health workers dispensing the drugs.

Health care cost: The cost of seeking care at the private sector was reported as higher compared to the

public sector. However, the conveniences and quality of care provided at the private health facilities was

seen as the most important facilitating factor to use the private sector.

3.2.3 Variance in health seeking behaviour

While there is a clear pattern to health seeking behaviour reported, there is also notable variation in the way

care is sought. This is defined by the following:

Type of disease: There was indication that people sought care from different providers depending on the

type of disease. For example, most malaria patients opted for “self-diagnosis” and purchase drugs over the

counter. Cancer screening was hardly sought, and in most such cases, health services were sought in

private facilities when the illness had advanced. HIV care seeking behaviour is affected by self-denial and

stigmatization. Few men were reported as seeking immediate HIV care, as a consequence of self-denial or

fear of stigmatization. It was also reported that some of those affected do not utilize ARVs and often prefer to

use herbalists.

“For cancer they don’t go for check-up for early diagnosis, so they just wait until it’s too late.” FGD,

women, Mombasa

The health seeking behaviour for diarrhoea among the working poor appear to be largely buying over the

counter drugs either from a chemist/pharmacy or small retail drugs outlets. This depends on the severity of

illnesses and the location relative to the sources of care.

Type of patient: There was preference to seek care from private health providers or public health facilities

depending on the type of patient. For example, mothers with under-five children often sought at public

facilities due to the fact that health care was free. Other respondents explained that for under-five children

the existence of child that waiting times were much shorter in private clinics and drugs were often available.

Also, women sought maternal health services at public health facilities, given that they are heavily

subsidized.

Severity of the illness: The pattern of health seeking behaviour was altered depending on the real or

perceived severity of illness. For example, for illnesses perceived to be less severe, such as malaria and

diarrhoea, consumers sought care with an herbalists, “self-diagnosis” and over the counter medication, while

for illnesses thought to be severe, such as cancer, consumers were treated at health facilities.

Rural vs. Urban: Generally behaviour between rural and urban poor did not show much variance in terms of

health seeking behaviour. A common pattern revealed is that health seeking among rural poor and urban

poor depends on the type of illness and available health services. As explained by many of the respondents,

for common illnesses such as diarrhoea, cough, fever and other sicknesses like malaria, self-treatment was

taken as a first action while people ‘waited to see’ if the symptoms would go away, preferring to seek

treatment from health facilities if illnesses persisted or worsened. Such conditions do not require complex

laboratory test and are easily treated with ‘over the counter’ medicines which are readily available in shops,

chemists, pharmacy and small drug outlets. Reasons for not seeking treatment from health facilities were

varied. For some, going to hospital for repeated illness was a waste of time, they simply bought the same

drug they were prescribed for the first time they visited the health facility if they perceive the symptoms are

the same.



I: what do you do when a person falls ill?

R: Buying medicine from the chemist and if persist we go to the city council hospital-FGD-Nairobi

R…we will first go to the chemists for drugs and if the illness persists that’s when we go to hospital. We go

to the chemists to ask for specific drugs that we usually get from the hospitals- FGD, Machakos

Some respondents, both urban and rural prefer using herbal medicines for care and treatment of illnesses.

For urban participants, herbal medicines were mainly sold by vendors, however, some of the rural

respondents cultivated some of the herbs used as medicines in their farms, as explained in the excerpt

below.

I: Are there any traditional drugs that you use when you have a cold? R: There is a drug that the Maasai sell.

I: What is it called?

R: I don’t know, I just buy. They say it treats forty two diseases. When you’re given you just take-FGD

Nairobi

R: There are those who know about traditional herbs so when they get sick they just uproot them and take

them- Mostly people have a belief that traditional medicine works best. And if it doesn’t work you Io to

hospital especially cases of stomach ache, diarrhoea and ring worms FGD-Busia

3.3 Provider Perspectives

The study included a range of facilities from small to large facilities with the number of staff varying with the size of the facility. Smaller facilities have one provider compared to large facilities that have between 2-7 providers. The large pharmacies provide products to retail pharmacies and general shops. Most of the facilities provide basic and comprehensive services. The cadre of staff provides different services ranging from laboratory, pharmacy as well as clinical services. In bigger facilities they have other administrative support staff such as accountants and or clerks. The client load varies from 20-30 per day for the small facilities to up to two hundred clients per day for larger facilities. The flow of clientele also depends on the season such as epidemiological patterns of diseases, festive season or season when finances are available. Smaller facilities see fewer clients as they are still developing a client base.

3.4 Factors influencing access to health services.

Access to services: Access is most commonly referred by the respondents as distance to the health facility

and length of waiting time for the services. It appears that the short waiting times at the private clinics and

pharmacies is the most important factor that attracts the working poor to seeking services with private

providers. Most of the respondents explained that their jobs are mostly paid for hours worked and therefore

appreciate short waiting time at the private clinics and pharmacies.

“We go to the county council hospital because they offer cheap services. On other occasions we go to the

private hospitals because in the government hospitals they only prescribe drugs for us to go and buy from the

chemists, the lines in the public are also quite long so we prefer borrowing money to take our relatives to

private hospitals for treatment”:

FGD Women Machakos

Quality of care: The quality of care was expressed as real or perceived but both had a significant influence

on the choice of health care by most study participants. Informants reported that private sector providers

often had the supplies and commodities required, the providers in the private clinics had good

communication skills and they offered friendlier services compared to the public sector.

Healthcare cost: The cost of seeking care at the private sector was reported as higher compared to the

public sector. However, the conveniences and quality of care provided at the private health facilities was

seen as the most important facilitating factor to use the private sector.

While there is a clear pattern to health seeking behaviour reported, there is also notable variation in the way

care is sought. This is defined by the following:

Key features of private sector providers

Size range from small to large facilities

They operate long hours six-seven days a week

Most of them do not have many branches

They provide services to a variety of clients, including the poor

Most of them rent their premises adding to higher operating costs



Type of disease: There was indication that people sought care from different providers depending on the

type of disease. For example, most malaria patients opted for “self-diagnosis” and purchase drugs over the

counter. Working poor suffering from diarrhoea appear to be largely buying over the counter drugs either

from a chemist/pharmacy or small retail drugs outlets. Respondents seeking cancer screening, and in most

such cases, health services received care in private facilities when the illness had advanced. HIV care

seeking behaviour is affected by self-denial and stigmatization. As a consequence, few men interviewed

reported seeking immediate HIV care. It was also reported that some of those affected do not utilize ARVs

and often prefer to use herbalists. The use of the chemist/pharmacy was often associated with illnesses not

considered serious and often they sought a prescription from the health workers dispensing the drugs.

“For cancer they don’t go for check-up for early diagnosis, so they just wait until it’s too late.” FGD, women,

Mombasa

Type of patient: The type of patient influenced whether a consumer seeks care from a private health

provider or public health facility. For example, a mother with an under-five child often goes to a public facility

because health care is free. Other respondents explained that for under-five children, the existence of child

clinics made the waiting times much shorter and often the drugs were also available. Also, many women

stated they seek maternal health services at public health facilities given the costs of services are heavily

subsidized.

Severity of the illness: Health seeking behaviour was influenced depending on the real or perceived

severity of illness. For example, for illnesses perceived to be less severe, such as malaria and diarrhoea,

many consumers would see an herbalists, “self-diagnosis” and purchase over the counter medication. While

for illnesses thought to be severe, such as cancer, consumers would seek treatment at a health facility.

3.5 Consumer ability and willingness to pay

The findings from the interviews show that the working poor regularly pay for health services and

commodities in the private sector. The focus group discussions revealed the poor are willing to pay when

they perceive the quality of health services in private sector is better than in the public sector. Also, the

working poor are willing to pay for specialized services, such as diagnostics, specialty care such as

cardiology and cancer treatment, as well as specialized drugs for diabetes and heart disease.

The poor consumers interviewed indicated they prefer private providers and stated they are willing to pay for

more services in the private sector if they were affordable. Interestingly, the private sector providers

interviewed held the view that most consumers were unwilling and unable to pay for their services.

Working poor’s health seeking behaviour has significant financial implications. The research revealed that

the poor have to interact with the health sector more times that their wealthier counterparts, increasing their

out-out-pocket spending with each encounter. Not only do the poor pay out-of-pocket, they incur other non-

monetary costs such as increase in illness severity, length of illness episode and economic losses due to

extended illness. The net effect is a “poverty penalty”.

3.5.1 What are the provider perspectives on consumers’ willingness to pay for health services?

The findings from the interviews show that opinion of health care providers on the consumer ability and

willingness to pay for health services are divided. In-depth interviews with health service providers revealed

that there are those who are sceptical of consumer’s attitudes toward fee-based healthcare services. Asked

about the challenges they face in providing health care, some of the private sector providers interviewed

explained that poor clients were unwilling and unable to pay for their services, as seen in the excerpts below:

Some of the patients are not able to pay because they don’t want to pay, so what we do is prescribe drugs

and then they go. When you look at our clinic, there are so many debts but to minimize it we just give

prescriptions for the patients to go and buy the drugs elsewhere-IDI-Clinic owner-Machakos

I: What about client inability to pay? Do you feel ike it is a challenge?

R: Yes. Some are not able to pay at all. Some get treated and never come back unless they have an

emergency. IDI-Private Hospital-Nairobi

I: How do you treat a poor person and a rich person? Do you treat the same or do you lower the price? Are

there special cases where you can lower the price?



R: Yes we do consider the pocket because you can’t leave the chemist when you are sick and you don’t have

medication. In pharmacy field we have generic and original…if you aren’t able to buy original and maybe

your situation is not so bad we substitute with generic and it will serve the same purpose-IDI-Pharmacy

owner-Nairobi

3.6 Working poor’s preference for the Private Sector

Several factors explained why the poor are prefer the private

health sector and seek healthcare and services in this sector

despite the economic costs. These factors mirror the literature

review and are primarily driven by the way the private sector

services are organized. How health services are organized,

managed and delivered also influence health seeking behaviour.

The respondents value confidentiality and believe that private

sector providers protect confidentiality more than their public sector counterparts. Many discussed concerns

of confidentiality in terms of laboratory tests and certain illnesses such as HIV.

The second most important factor is the availability of equipment and supplies. The respondents shared that public health facilities lack medicine and often experience stock-outs. The consumers blamed KEMSA for the lack of essential medicines and commodities. Corruption featured prominently in the discussions as well. The interviewees claimed that due to corruption, the MOH providers sell public medicines to private providers; that many public providers steal supplies and use them in their own private practice. And many stated that poor government enforcement of licensing, particularly among informal providers, also creates concerns about quality of drugs.

“So according to me maybe a bit, so with me the

major issue is supplies, they are not adequate. Given a

workload, maybe a given dispensary within the

supplies they get that particular time then maybe the

supplies are over before they get another supply. So it

reaches a time maybe the supply within two to three

months there are no drugs so they intend to throw

these people outside where we get them as private

sectors.”

FGD providers Machakos

Long waiting times in the public facilities was cited as another reason for use of the private sector facilities.

Government facilities were reported to often have long queues. The majority of the working poor reported

being paid on an hourly basis and there waiting time represented loss income.

“Long queues in public hospitals discourage us from going to hospital, so we prefer going to the shops to buy

the drugs.” FGD Men Kisumu

“You are required at your job since are supposed to report at a particular time and your boss does not want to give

you time so you prefer going to the chemist and get quick drugs and go back to work.”

FGD Men Nairobi

Limited or no access to a trained medical staff person is another factor influencing the poor’s use of a private

sector facility. Poor government recruitment is one reason why public sector are understaffed.

“So you find a very good private hospital has seven or ten employees but you will always find over twenty

personnel. Most of them are government employees and they are on contract or locum.”

FGD Health workers Garissa

Finally, private facilities are often open longer hours and on weekends.

“ And another thing to add on top of that one, clients provide their confidence, you see at times like me I get

more calls when am in the house, somebody wants to see me, even if I try my best to connect that particular

patient to the staff in the public sector he cannot willingly go there. He just waits for me until I come and

provide that drug for that patient. So that confidence actually is a contributory factor to people flowing into

private sector and avoiding going to public. FGD providers Mombasa.

Neglected illnesses for the poor

Non-communicable disease (cancer, diabetes, heart disease)

Dentistry

Gerontology

Respiratory infections

Metal health

Reasons why poor prefer the private sector Perceived quality of services

Confidentiality

Convenience (longer working hours)

Easy access to the facility

Positive provider attitude and behaviours

Availability of specialised services

Shorter waiting times

Availability of staff, particularly doctors

Availability of equipment and supplies



4 Discussion

This is the second section of key findings and is focused on the private health sector and their role in

delivering health services and products to the working poor. Section 4 focuses on private sector prices and

their strategies to help the working poor pay, a description of the range of clientele served by the private

sector, the most common illnesses that the private sector finds among the working poor, and concludes with

the principle challenges they confront.

4.1 Overview of Private Health Sector

The study interviewed a range of private providers who

managed and operated facilities ranging from small to large

facilities located in both urban and rural areas. The smaller

facility typically had one provider – the owner/physician.

These facilities aim to deliver basic yet comprehensive

services including laboratory, pharmacy as well as clinical

services. The client load varies from 20-30 per day for the

small facilities. Smaller facilities see fewer clients as they are

still developing a client base.

On the other hand, the larger facility employed two to seven providers in addition to administrative staff such

as accountants and/or clerks.

The larger facilities would serve upwards of two hundred patients daily. Larger pharmacies would also

provide products to smaller retail pharmacies and general shops in their catchment areas.

The flow of clientele also depends on the season such as epidemiological patterns of diseases, festive

season or season when finances are available.

4.2 Private Sector Costs and Prices of Services.

Prices charged in the private sector Prices charged in the private vary depending on the size, type of facility and location. Some providers have a price list accessible to clients but it is often subject to change. In some cases, providers purposely do not display their price list as a strategic move to charge different prices depending on the perceived ability of the client to pay. Although the private sector prices are higher than the fees and other incidental costs consumers need to pay in the public sector, the private providers interviewed generally thought their prices are too expensive because their clients often came back for more services. The average prices provided for different services are presented in Table 5 below. Table 2. Private sector prices of services Costs of services Type of services

Free – KES 330 HIV testing

Free Treatment of TB

KES 150-300 Family panning

KES 8000 Maternity services

KES 100 Malaria lab test

KES 100-200 Typhoid

KES 200 Blood sugar tests

KES 200 Urinalysis

KES 100 Stool

Cost drivers for private practices

Private provider reported that operating costs are the main drivers. These include labour, rent, utilities such

as water and power, drugs and other supplies, and finally license fees. Most of the providers reported that for

effective service delivery, the private sector providers may need working capital to increase their ability to

deliver quality services.

Key features of private providers interviewed

Size ranges from small- to large

Operate longer hours than the public sector – six days weekly

Most providers own and manage only one facility

Most private providers interviewed serve the poor



“Electricity sometimes goes up; you know here electricity must be used for 24 hours. You find electricity bill is

very high”

FGD chemist workers Nairobi

“We pay 30,000 per month and license for the whole year is 25,000.”

IDI Health facility owner Machakos

“The major cost of a product that consumes most of our budget is medicine including the laboratory reagents

which are also consuming quite a lot. Of course I’m talking about recurrent expenditures because I’m

assuming the machines are already in place. So it is just drugs, salaries. I think those will be the major costs.”

IDI Health facility owner Busia

Setting prices Private providers understand the relationship between costs and price. The private providers also shared the various factors influencing how they set their prices (See Text box). The factors are presented in order of importance. Key among them is competition with other private providers in their community. Another is clientele; many demonstrated flexibility in pricing due to poverty and economic hardship. Private providers help their poor clients by either reducing the price or by offering flexible payment modes like payment in instalments.

“The price is determined by your cost. Until you receive goods from the supplier and check the invoice that is

when you can tell your price.”

FGD providers, Busia

“…And it’s known in pharmacy. You multiply by 1.33. if you want to know the cost of selling an item, you

multiply the price you purchased the products with 1.33 to retail price.”

FGD providers Nyamira

Private provider accept payment through a variety of mechanisms which is linked to the size of the private

facility. Clearly smaller providers rely on cash payment and at times, in-kind payments. While the larger

facilities could accommodate checks, Mpesa and insurance – both public and private mostly in urban areas.

The mechanism preferred and used for payments was reflective of the scale of the health facility and the

type of clientele they serve. For example the larger facilities served patients with health insurance and

checks, and were mostly located in urban areas. The smaller facilities accepted cash (OOP) and Mpesa

payments, and were located in rural and peri-urban areas.

4.3 Business Strategies to work with the poor

Marketing strategies

Few private providers use market to reach new clients and thereby expand services. There are several

reasons why:

> The medical community, particularly doctors, believe that it is not appropriate and not needed

> The cost of advertising is prohibitive for small business.

> Limited knowledge and experience by private health sector to market their products and services.

“We belong to the xxx whereby we were not allowed even to advertise you just write xxx Medical Clinic then

you offer the services which is required then that one will advertise for itself.”

IDI Health facility owner Machakos

Bigger facilities do have experience in marketing and utilized mainstream media to advertise themselves.

Marketing activities include use of flyers, bill boards, radio and television spots and more recently social

networks. Smaller facilities tend to rely on “word of mouth” based on delivering good quality service and

client service.

Factors influencing provider prices Operating costs, particularly staff

and drugs

Competition with other providers

Type of clients

Location of services

Cost of license (provider and facility)



Financing strategies

Access to capital appears to be a major challenge for private sector providers, which affects expansion and

quality of service provision. Most private providers noted that the start-up capital is largely based on

investor/provider savings or through loans. Occasionally, there is donor support linked to faith-based

facilities. Continuous capital support often comes from credit facilities, especially with regards to supplies.

The credit system operates under different arrangements as agreed upon by the service provider and the

finance provider.

“When you want credit somehow we are given credit when you are a regular customer there you see then

you leave your details also there when you are given credit then you are given 6days or 30 days to settle.”

IDI Health facility owner Isiolo

4.4 Private sector clientele

Client profile

The study also explored the characteristics of clients who frequent the private sector. Findings show that the

private sector serves both the poor and the rich alike. The private sector providers interviewed estimated that

their poor clientele earn about 3000 Kenya shilling per month. The clients are geographically spread out

depending on the locations of the facilities.

Moreover, the findings revealed that the private sector targets all persons along the socioeconomic

spectrum. This strategy permits private providers to boost client volume which helps drive their unit costs

down; to better manage cash flow and to cross subsidize their poor clientele who cannot afford to either pay

full price or have to pay on instalments.

Ability/willingness to pay for private services

In general, the private providers interviewed shared that their clientele were willing to pay for services

because most of the services they offered were not available in the public sector. These providers noted,

however, that their clientele’s ability to pay for the services was somewhat diminished by the ‘high’ prices set.

Some of the private providers have made attempts to estimate the cost clients were willing to pay for various

services. For maternity services majority of the female respondents reported a price of KES 2500, while for

common illness such as flu, they reported paying approximately KES 200-500. The excerpts below

demonstrate consumer’s perceptions on affordability and willingness to pay.

“We should be allowed to use the NHIF cards even if we are not being admitted to the hospital. For illnesses

like common cold we should be charged about 200 Shillings, at most 500 Shillings, this is because those

people are there for business and they have to pay rent and the staff.”

FGD women, Kwale

“They should even consider reducing the fees they charge to their clients. Maternity fees worth 8000 Shillings

is so expensive, if it was 2500 Shillings it would be fair.”

FGD women, Nakuru

Private provider flexible terms of payment

The private sector has developed two main ways to accommodate the poor. First, the poor pay as much as

the rich for drugs and other health commodities but are allowed to pay for half doses of medicines or pay in

instalments. This coping system may enhance drugs resistance through irrational drugs use. It also depicts

a repeated cycle of potentially inadequate treatments that may spur repeated visits, making access to care

expensive. The second approach is to allow alternative modes of payment that attract a value that may be

monetary or otherwise.

4.5 Common Medical Problems

The common illnesses that private providers see among the working poor included HIV/AIDS, malnutrition,

diabetes, pneumonia, malaria, cancer, diarrhoea, typhoid and anaemia. In addition to the illnesses identified

by the working poor, health workers mentioned urinary tract infections, respiratory infections, pelvic

infections, intestinal worms. Specifically for Isiolo County the health workers identified brucellosis as a

common illness whereas in Mombasa and Kwale counties conjunctivitis was often mentioned. The main

types of cancers identified were breast, cervical and kaposis sarcoma.



“Ok, generally, HIV aids very common, Aids leading to other diseases like tuberculosis, yeah.” FGD Health

workers Kwale

When asked to prioritize, health workers in this study identified HIV, cancer, diarrhoea, malaria and

pneumonia. However, many health workers felt that there were additional priority illnesses specific to

children – upper respiratory illnesses and malnutrition.

“Even malnutrition they don’t seek treatment. When the child is

about to die is the time they go to the hospital. They lack

knowledge and understanding of seriousness of malnutrition

and at times they are ashamed.”

FGD Health workers

“Like today out of the 20 cases that we had 4 of them were

diarrhea cases so in other facilities they may change because it

depends on the month and the season in other seasons the

frequency increases like last December the frequency was high

so you find even the most admission cases in children are

diarrhea like during the rainy season the cases are high”

FGD providers Nakuru

Four key differences emerge in the type of illnesses that are commonly experienced across private sector

sites.

Differences between the diseases cited by women and men. For example, women and men also cited

different illnesses such as problems during the menstrual cycle, stomach aches and ulcers. There were no

major differences between women under 25 years and those above 25 in terms of illnesses that were

commonly experienced. However men over 25 years in Machakos pointed falls from construction sites as an

additional problem.

“Injuries that people get while fighting or at work for example falling during construction” FGD Women

Machakos

Differences in common illnesses based on seasonality and geography. Geographic variations linked to

either rainy or sunny periods of the year were noted. Geographical location, with arid and semi-arid region

citing diseases such as malaria, typhoid, diabetes, blood pressure, HIV/AIDS, diarrhoea, sleeping sickness.

It is also clear that the location of certain features such as presence of army barracks and tourist sites was

perceived to propagate certain illness for example in Isiolo women noted.

“Episodes of malaria is not seasonal it is all the time. Pneumonia occurs during the cold season, That is...in

term of seasons that is during the colds season that is from March to May.”

FGD Women Busia

“Are many people affected with TB? Yes, we have Muslims and because of their customs of eating the

prevalence is high. The rate of HIV/AIDS is high because of a lot of army barracks here in Isiolo County and

the women and girls go to town to be with them. Pneumonia affects the motorbike drivers on the road

because of the cold.”

FGD Women Isiolo

In Busia the top diseases were malaria and ring worms. In Isiolo, they ranked malaria and HIV/AIDS as the

most common illnesses, especially as experienced by women. In Kiambu pharmacists based the common

illnesses on what drugs sell most.

“Malaria it occurs during the rainy seasons, HIV/AIDS the 2nd because they are many drunkards who sleep

around under the influence, typhoid because our water is really dirty and not of standard, TB because these

area is a dry land and pneumonia”

FGD health workers Isiolo

“Flu, common cold, chest conditions like bronchiolitis, abdominal discomforts like diarrhea, typhoid fever,

brucellosis and dysentery” FGD health workers Kiambu

“I think is malaria, diarrhea and vomiting, ring worms and I think we had forgotten epilepsy and lastly HIV

and AIDS in that order.”

Private Providers top five diseases among working poor

HIV/AIDS

Cancer

Diarrhea

Malaria

Pneumonia Among poor children

Upper respiratory illness

Malnutrition



FGD-Health workers Busia

In other sites such Narok and Busia dental problems were cited as a common problem.

“There are quite a number of problems, for me am in dental department so the main problems there is the

dental carries and other dental diseases I think those are the major diseases that we deal with in dental

department”

FGD-Providers Narok

“Tooth decay is also a problem you find someone has all the teeth rotten it is called dental tooth decay if you

go to hospital when they pull the tooth out the healthy one also start decaying and if you take it to the

Nambale Centre the doctors there are not qualified they just pull the tooth out just for the sake and you get

infections which sometimes lead even to death”

FGD women-Busia

Difference in illnesses based on demographics. In Busia, women cited variations with the age groups with younger children experiencing certain condition.

“Skin rushes on children are also so rampant children below five months you get that they have rushes all over if you

take them to hospital they give you amoxilin and it doesn’t work and colds also when you walk you find that

everybody has a cold just that.”

FGD women Busia

4.6 Neglected Health Priorities in the Private Sector

Most of the working poor who participated in the study mentioned

that the services available to them were generally inaccessible in

terms of price, quality and physical location. While there are health

priorities such as HIV/AIDS, malaria, child health and maternal health

which are relatively accessible, there are others areas that are

grossly underserved.

The main reasons cited why the working poor do not receive these

services were health workers in medical facilities in their

communities lack training and skills in specialties, and the price for these services tend to be too high for the

working poor to afford.

4.7 Challenges Confronting Private Sector

The private providers interviewed experience many

challenges similar to private providers in other developing

countries. The challenges found through FGD and IDIs are

organized by enabling environment, business climate,

competition and asymmetry of information.

Enabling Environment. Stakeholder interviews with

private providers highlighted many of the legal and

regulatory barriers they confront, particularly in serving the

poor. They include:

Private sector role and contribution towards national priorities unclear: To date, there is still no MOH policy

and strategy on how to engage and work with the private sector. There is no consensus or clarity on what

role each sector should play, and under which conditions each sector should pay its role. The private sector

is often unaware of national health priorities and therefore unable to align its activities to address these

priorities.

Regulatory processes “opaque” and cumbersome: Institutional arrangements and transparent procedures to

partner with the private sector do not exist. And private providers have to negotiate a myriad of MOH

departments to secure the necessary approvals and licenses to operate as a private and health business.

Uncertain MOH support and commitment to the private health sector: The health sector is currently

experiencing a lot of change and turmoil. There is a new MOH administration in place and to date, they have

had limited dialogue with the private health sector.

Neglected illnesses for the poor

Non-communicable disease (cancer, diabetes, heart disease)

Dentistry Gerontology Respiratory infections Metal health

“The main challenge is one because of the old mistrust, again if you find some private practitioners will not meet the standards of the equipment’s. Once the guy puts up a hospital he might not employ the qualified people and he might not have the right equipment’s. So you go there and tell them that you cannot start until you meet the basic requirements”.

IDI, private clinic owner, Busia



> Weak enforcement of government rules: The private

sector largely continues to operate with minimal

oversight. Quality in the private health sector, still a

major concern, can be significantly improved through a

combination of better enforcement and incentives. The

MOH has many of the instruments in place but has

underinvested in capacity to enforce standards and

norms.

> Limited incentives to serve the poor: The MOH does not have in place a strategy and/or policy guiding

the public and private sectors to focus its efforts to reaching underserved population groups like the poor.

And the government does not routinely use incentives - such as tax relief, certificate of needs, and

subsides - encouraging the private sector to invest in health services reaching the poor.

Business Climate. Many private providers consider the Kenyan health market attractive for growth and investment and the government has become more receptive to working more directly with the private health sector. Challenges remain, however, including: > High Cost to set up a health business: Most private

providers consider existing regulations to be reasonable

and welcome the opportunity to be fully licensed as a

competitive advantage with consumers. However,

managing multiple licenses and inspections from different regulatory agencies is confusing, costly and

time consuming, resulting in higher cost to entry.

> High cost of inputs: Staff and drugs are the two main cost drivers in a health business. Others cited the

equipment as well as the high cost of property in urban areas.

> Access to finance: In general, larger hospitals and pharmaceutical manufacturers have access to formal

credit. However, smaller facilities and solo practitioners – the private provider group most likely to serve

the poor – cite access to finance as a major constraint. Lack of access limits private provider capacity to

expand services and invest in quality improvements.

> Poor business and financial management skills: Many small private practices do not have some of the

basic tools and skills to analyse costs or profits. Moreover, several provider recognize they struggle to

identify potential target market and lack skills to market to prospective consumers.

> Locating services in poor neighbourhoods brings unique management problems: Government investment

in infrastructure are concentrated in urban neighbourhoods – not poor communities – driving the start-up

cost for basic inputs like water and electricity. Crime and political insecurity is higher in peri-urban areas,

making it difficult to attract skilled workers, there are fewer trained personnel in/or near these

communities, and specialists are unwilling to commit to working in these communities.

Market Competition. Private providers state that competition is a big challenge and comes from multiple sources. > Competition with informal providers. Private providers

consistently reported that unlicensed facilities and/or

illegal workers in the informal sector represent one of

the most difficult areas of competition. Such facilities

are reported to have lower prices compared to those who are fully licensed and employ qualified

personnel

> Other private providers. The private for-profit health sector is dominated by small private practice – solo

practitioners. Because of competition with other small practices, many private providers feel compelled to

invest in medical equipment to attract consumers. There is little incentive and limited experience in

forming “group” practices to minimize risk.

“Because they discriminate against people from

the private sector and then the rampant levels of

corruption, for instance the drug inspectors they

are government personnel but they are coming to

harass us in our facilities, they are just after

money.”

FGD, Health workers, Machakos

“There a district hospital around. There prices are

very low compared to ours, you know the prices

are subsidized by the government but with us we

get them directly from the suppliers.”

IDI, pharmacy owner, Nyamira

“The high cost of equipment’s and lack of skills of

the health providers are our challenges, we also

have the inability of clients to pay and lack of

awareness that this clinic exist and that is why we

do sensitization of the community often.”

IDI, Clinic owner, Isiolo



> Competition with the public sector. Many of the private providers claim “stiff competition” from MOH

services. Often middle income clients switch providers to receive certain services, such as deliveries, for

“free” or at a “subsidized” rates in government facilities. It is difficult to compete with MOH who receive

access to favorable prices for key inputs such as infrastructure, drugs and equipment.

> Crowding out by donor subsidies. There are two forms of donor subsidies creating unfair competition:

first, free products “dumped” in the market place such as free FP methods, childhood vaccines and

malaria bednets and second, subsidized inputs to private providers participating in donor programmes.

Private providers they cannot compete with free products or reduced prices artificially created through

donor subsidies.

Asymmetry of Information. There are persistent problems of poor communication and information sharing.

On the public sector side, the MOH struggles to motivate the private health sector to regularly report its

activities to the MOH health management information system. On the private sector side, one key constraint

is exclusion from MOH policy and planning processes and limited communication between sectors.

Information gaps include:

> National health of priorities: Private sector lacks information due to infrequent participation in policy

formulation and planning processes, limited distribution of key government documents and strategies and

no interaction between the sectors.

> Regulations and standards: The MOH often does not include private sector organizations in its efforts to

update and modernize regulations and standards, does not consistently communicate important changes

in and/or widely disseminate revised regulations and standards with the private health sector.

> Clinical training and updates: Although donors invest millions of dollars to train MOH staff, very little is

allocated to private sector providers. Private provider also need to keep up with technology, new

treatments and products and other advancements.

4.8 The Poverty Penalty

As a result of how decision are made and acted upon, the poor are penalized by not having access to an

efficient and equitable health system. As the prior sections revealed, depending on the illness, the consumer

– usually a mother taking care of a sick child – will first resort to self-medication, purchasing some form of

medication at a drug shop or kiosk located in her community. This is the mother’s first experience in the

health system and her first out-of-pocket payment to treat her child.

Usually, the substandard “drugs” do not successful treat her child’s illness, and the child’s health worsens.

The mother then decides, without conferring with her husband because all decisions related to the children

are within her purview, to consult an informal provider in her community. She visits the traditional healer for

a variety of reasons – convenience, trust and cost. Indeed, the mother cannot afford to pay the consultation

fee at either private or public health facility but the informal provider offers flexible payment terms. This is the

second time the poor mother has to pay to treat her increasingly sick child. The low quality and substandard

medication received from the informal provider often results in the child getting sicker.

As the illness progresses, the mother decides to see a trained health provider and for the first time enters

into the formal health sector. At this point, the mother may first go to a public facility. But she will pay yet

again for an administrative fee and purchase of drugs at a private pharmacy because the public facility does

not have the prescribed drugs in stock.

In severe cases, however, the mother will go directly to a private provider. In this case, she will have to

consult with her husband or other important male figure in the household because of the cost implications.

Depending on how the illness progresses and cost of treatment, the mother will bounce between the public

and private sectors several times until her child is, hopefully, successfully treated. Under this scenario, the

mother has to pay each time she interacts with a healthcare providers, driving the cost even higher to treat

one episode of illness. Because she is poor and cannot directly access affordable healthcare from a

trained provider in the first place, the mother and her child are penalized by the health system.

Working poor’s health seeking behaviour has significant financial implications. The research revealed that

the poor have to interact with the health sector more times than their wealthier counterparts, increasing the



cost with each encounter. Not only do the poor pay out-of-pocket, they incur other non-monetary costs such

as increase in illness severity, length of illness episode and economic losses due to extended illness. The

net effect is a “poverty penalty”

The fact that the working poor pay out of pocket for each time they seek health care indicates that there are

opportunities for the private sector to minimize the number of interactions the patient has with the health

system and reduce the poverty penalty for the working poor.



5 Policy Recommendations

With many African countries, such as Kenya, with worsening poverty and health outcomes, it seems

ineffective to entirely charge the government with the responsibility of health care for all its citizens. The

private sector in health has a role to play in improving health outcome especially among the poor. The study

was guided by the following research questions and the findings help inform potential private sector

interventions that will benefit the working poor.



population?


population?



services?

Smith and colleagues outline several ways in which interventions can be designed to increase coverage of

services, improve quality and control costs through the private sector. Table 6 describes various

opportunities and approaches for working with PSPs in the Kenyan market.

Table 7. Matrix of identified strategies to working with PSP for the poor Intervention objective

Interventions geared towards policy makers

Interventions geared towards providers

Enabling consumers and their representatives

Increase coverage of products and services with a public health benefit which are affordable for the poor

Strategy 1

Lower policy, regulatory and fiscal barriers

Remove barriers to private sector entry to market

Liberalize scopes of practice for key health cadre in private sector

Strategy 2

Recruit and network pharmacies into retail networks

Strategy 3

Recruit PSPs into an accredited network for specific health services with a public health benefit

Strategy 4

Contract with PSPs for packages of essential health care

Strategy 5

Market private sector services among priority target groups

Strategy 6

Introduce demand-side financing to remove economic barriers for priority target groups

Limit harmful practices and improve technical quality of care among PSPs

Strategy 7

Enact and enforce quality standards

Strengthen and enforce provider / facility licensing

Better integrate private sector in quality supervision

Strategy 8

Provide training supports and incentives to PSPs to conform to good practice norms

Strategy 9

Enact consumer protection law and raise awareness of consumer rights

Strategy 10

Increase consumer’s knowledge thru community education campaigns

Make PSP services more affordable

Strategy 11

Publish PSP prices

Encourage price minimums for priority services

Use insurance and contracting to influence prices

Strategy 12

Organize PSPs into group practices, insurance schemes and contracting

Strategy 13

Publish information to users on maximum permitted prices

The qualitative research reinforces the growing knowledge of the private sector role in delivering services to

the poor in Kenya. Although the private health sector face many challenges in serving this target group, they

are keenly interested in expanding their services to reach more clients – even the poor. Moreover, the

research shows that in many cases, the private sector is the provider of choice. Yet price makes access to

private facilities and providers unattainable.



The research revealed several opportunities to expand the private sector role while improving the quality and

affordability of their services to benefit the poor. The qualitative study will guide the PSP4H programme as

they enter into the design phase to develop partnerships with private providers that will reach the working

poor in Kenya.



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7 Annex 1: Tools

Stakeholder Interview Guides Target audience There will be 3 categories of stakeholders.

1. The beneficiaries – the demand side (the poor) 2. The investors – the supply side 3. Policy environment players

Research Questions and Hypotheses

a) Beneficiaries 1. Is it commercially viable for private-for-profit and informal sector providers to offer quality,

affordable health services and products to poor customers and clients? Which products and services?

2. What incentives (financial and non-financial) motivate (encourage, facilitate) private-for-profit and informal providers to:

a. Enter into certain markets (supply chain, different health areas, etc.) b. Serve specific consumer groups (poor)

3. What factors enable private providers (formal and informal) to stay in these new markets and to expand services/products to the poor customers and clients?

4. What enabling factors (e.g. training, licensing, franchising, task-shifting) contribute to increasing quality and affordability of private sector health services and products delivered to the poor? (perverse outcomes or unanticipated outcomes?)

5. What are the characteristics and main drivers of the human health pharmaceutical supply chain, overall and particularly the parts of it which reach the poor? How has it changed in recent years?

6. Why is the supply chain the way it is? How does it differ from that for comparable products (such as agricultural chemicals for small farmers) and from neighboring countries?

For-profit service providers and shop-keepers selling medicines will find it commercially viable to offer

better quality care and products to their poor customers/clients.

It will be possible to identify incentives which persuade for-profit providers and

shopkeepers selling medicines to change their business practices in ways which benefit

poor people, and which can be sustained by the market after interventions have ended.

Players in the commercial supply chain will find it is commercially viable to make changes which will

benefit the poor people who buy their products.

It will be possible to identify incentives which persuade players in the commercial supply chain to change

their business practices in ways which benefit poor people, and which can be sustained by the market

after interventions have ended.

Improvements in the market for skilled health personnel (e.g. training, licensing, franchising, task-

shifting) which in theory should benefit poor people will actually have an impact on the quality and value

for money which poor people get in the for-profit market.



b) Investors and Policy Environment

7. How active in this market are shop-keepers (formal and informal) selling medicine and for-profit health care providers? What are their qualifications and employment history? How does this vary by location and other factors, and how has it changed over recent years?

8. Why do for-profit providers behave the way they do? And how does their behaviour vary by type of client/patient, by health condition and other factors?

9. What is the extent of ‘dual practice’ (government health workers who also practice privately)? What are the drivers of this? How has it changed in recent years?



Beneficiaries – FGD guide

Introduction

Please identify a private setting for the FGDs. I would like to thank each of you for agreeing to be a part of this focus group discussion. My name is ………………. . I will be leading the discussion session. My colleague here is called …………………; will help by taking notes about the discussion. We also request you to allow the session to be audio-taped so that we do not miss writing down any of the ideas. The purpose of conducting this discussion is to know your views in health care seeking patterns. The information collected will be useful in helping to understand how communities utilize various providers in health care. This will help the Ministry of Health and other stakeholders to plan effectively. There are no wrong or right answers. Please be assured that your personal details or what you say as a person will not be used at any time. What you say is therefore confidential and anonymous. We will ensure confidentiality with regard to all the information discussed and in particular, the information in the tapes will be destroyed after analysis. This discussion will also be anonymous – your names will not be recorded in the notes; rather we shall assign codes to the names. You are therefore encouraged to participate actively and to feel free during the discussion.

Do you have questions at this point about this discussion? Ask each participant to introduce himself or herself in turn. After the introductions, open up the discussion by asking the questions below. Project introduction: – exploring innovative approaches that will lead to improved health outcomes for the poor. This will be implemented through the private sector. Inclusion criteria – We are talking to different stakeholders in the private health sector and we think you might be in a position to provide us with information that will assist us to create the products and services that will benefit the poor. Participation to the discussion is voluntary and the information gathered here will be

Date of discussion: Moderator:

Venue : Note-taker:

Time start: No. Participants at start:

Time stop: No. Participants at stop :

Catchment site for FGD/facility County:

Participant Interview Number Gender (M/F)

Age Highest Level of Education

occupation family size

1

2

3

4

5

6

7

8

9

10

11

12



confidential. There is no right or wrong answer and everything you tell us will be appreciated. The discussion will take about 45minutes to 1 hour. Target Audience: Working poor from urban and rural areas/men and women/married with children and single Guide Questions: 1. What kind of health problems do you or a member of your family face? (List)

Which of these are the most important? (List top five) (Probe for severity, frequency and how wide spread)

2. What do you do when you are feeling unwell/sick with XXXXX (insert priority illness identified

above)? (Probe for different scenarios - e.g. self-treat, go to formal healthcare provider, go to a tradition

healer/friend) What do you do when a member of your family is feeling unwell or is sick? (Probe for different scenarios - e.g. self-treat, go to formal healthcare provider, go to a tradition

healer/friend)

3. Where do you or your family members most often go for treatment? (Probe for the different sources of healthcare provider and facility level) - Government health facility (probe for type of facility-hospital, clinic, and health post) - Faith-based facility (probe for type of facility-hospital, clinic, and health post) - Non-government/foundation/charity (probe for type of facility-hospital, clinic, and health post) - Private pharmacy, drug shop - Traditional healer

-Other Focus: What drives the choice made for care seeking?

4. Why did you use the XXXXXXXXX (insert the type of provider/facility level)?

(Probe for reasons such as cost, distance, quality of services, convenience, provider attitude, personal preference)

5. Are there illnesses that you don’t seek treatment for? Which ones? Why?

6. Who makes the decision in your household to go seek treatment?

(Probe for description of the individuals involved, when the illness is discussed, who makes the final decision?)

7. Do you pay for the services you receive in the public sector? If so, a. Which services do you pay for?

(Probe for the type of services e.g. maternity, FP, under-fives, lab services etc.) b. How much do you pay?

(Probe for prices (or estimate) for different types of services) c. How do you pay for the service?

(Probe for mode of payment e.g. cash, insurance, kind, installments, reimbursement, etc.) d. How much would you be comfortable paying? (probe for amount) e. Which services don’t you pay for? Why? E.g. offered free.

8. Do you pay for the services you receive in the private sector? If so,

a. Which services do you pay for? (Probe for the type of services e.g. maternity, FP, under-fives, lab services etc.)

b. How much do you pay? (Probe for prices (or estimate) for different types of services)

c. How do you pay for the service? (Probe for mode of payment e.g. cash, insurance, kind, installments, reimbursement, etc.)

d. How much would you be comfortable paying? (Probe for amount)

e. Which services don’t you pay for? Why? (E.g. offered free, included in health insurance, etc.)

9. On average, how much do you pay for health services per month?

Approximately, how much does this XXX (insert amount) represent as a percentage of your



total household income? 5 %, 10%, 20%? Are there times when you do not seek treatment because you cannot afford to? How often

does this occur? FOCUS: Are there any other circumstances other than cost that makes you not to seek

treatment? (Quality, provider behavior etc) What do you do in such circumstances?

9. Generally, where do people purchase their medicines in this community?

(Probe for healthcare professional, pharmacy, drug store, traditional healer, other?) a. Why did you use these facilities? XXXXXXXXX (insert the type of facility)?

(Probe for reasons such as availability, cost, convenience (distance, hours, days open), availability of health professional, provider attitude)

b. What drugs/medicines do they purchase most frequently? c. On average how much do people pay for medicines per month? d. Approximately, how much does this XXX (insert amount) represent as a percentage of your total

household income? 5%, 10%, 20%? e. Are there times when people do not buy drugs because you cannot afford to? f. Under what circumstances? g. How often does this occur?

10. In your opinion, what do people consider to be quality health services?

(Probe different characteristics: -Convenience (distance, hours) -Short waiting time -All services under one roof -Cleanliness (water, power, sanitation) -Friendly provider/friendly environment -Qualified staff (education, training, licensed by government) -Availability of drugs -Adequately equipped (water, electricity, etc. -Other

11. To make health care better for you and your family, what do you think should be done to improve

your experience in health services? Do you have any questions for us about this discussion or this study?



Investor – In-Depth Interview Guide PART A: GENERAL INFORMATION

Name of respondent (Optional)

Occupation/business type

Age (Years)

Gender:

Time interview started:

Time interview ended:

Name of note taker:

Name of interviewer:

County

Script code:

Project introduction – exploring innovative approaches that will lead to improved health outcomes for the poor. This will be implemented through the private sector. Inclusion criteria – We are talking to different stakeholders in the private health sector and we think you might be in a position to provide us with information that will assist us to create the products and services that will benefit the poor. Participation in the discussion is voluntary and the information gathered here will be confidential. There is no right or wrong answer and everything you tell us will be appreciated. The discussion will take about 45minutes to 1 hour. Target Audience: Healthcare providers and business owners, rural/urban providers, different facility levels (hospital, clinics, diagnostic labs, pharmacies), different segments in private sector 1. Can you please provide a general description of your business/ practice

a. What is the nature of your business? (Probe: strategy, positioning, uniqueness, etc) b. How long have you been in business? c. What types of health services/products do you offer? d. Do you have specialized services? (Probe for maternity, GBV, psychiatrists) Why this services? e. How do you market your services to your potential clients? f. How many clients/customers do you serve? (per day? Month? etc)

2. Now we would like to ask you some basic questions regarding your facility

a. Do you own or rent this facility? b. What type of facility is this (dispensary, health center, pharmacy, nursing home, hospital, other) c. Is this health facility classified as private for-profit, FBO, NGO, Other? g. Do you have more than one facility? If so, where are they located? (Probe for satellite clinics and

franchises) h. How many hours a day is your facility(ies) open? (Probe: Evening, overnight, 24 hours, weekends,

etc) i. How many days a week is your facility(ies) open?

3. How many staff do you employ? What cadres of staff do you have working for you? (Probe for specialists, medical officers, clinical officers, registered nurses, pharmacists, pharmtechs, lab technologist, others)

4. Can you please provide an idea of prices for your products/services a. What determines your pricing? (probe: (e.g. actual costs, industry practice, what competition

charges, regulation and licensing, how?) b. Is there a variance in pricing for the same service for special groups? (Probe if the reduce/exempt

charges because of inability to pay, vulnerable population group, etc.) c. For the services you do not charge for, how do you recover your cost? d. Do you have a price list available for your clients to see?

5. Can you describe what type of clients you work with?

Probe e.g. geographic, socio-economic, gender a. How do your clients pay for products/services? (e.g. Drugs, Lab test, etc)

(Probe for cash, voucher, installment, and insurance) For clients who mention insurance probe for NHIF, micro-insurance & private insurance)

b. Do you offer credit for your services?



c. In your opinion, do your patients consider these prices expensive? d. How do they compare to similar public services?

6. What internal challenges have you encountered in delivering healthcare services/products? Have you encountered any of the following challenges?

a. Lack of facilities / space b. High cost of equipment c. Lack of skills (provider) d. Poor returns e. Client inability to pay f. Unavailability of material/supplies g. Lack of awareness by clientele h. Other? (explain)

7. What external challenges do you encounter in running your healthcare business?

a. What types of licenses are you required to have? (Probe for professional or business licenses or any other and their availability)

b. Are you fully licensed? c. Are regulations on the establishment of private practices overly burdensome? d. Do they prevent private practitioners from establishing practices? e. Are there regulatory requirements that unnecessarily raise your costs? What are these? f. Do you view the existing regulations as fair and fairly administered? (probe: corruption) g. Do you think there are providers who compete unfairly with you because they are not properly

regulated? If so, who? 8. How do you finance your business/ practice?

a. What is your source of equity/startup capital? (family, savings, donors) b. Do you use credit? What is the source of the credit? (Probe: Bank loan, sacco, family, donors) c. Under what conditions do you obtain credit? (Probe: interest rates, collateral/security) d. Are micro-lending programmes targeting health care providers? e. Do you receive donor funds? If so, for what activities? f. Do you have unserved financing needs to expand your business? If so, which ones?

9. Is there a need for upgrading specific management skills for your business?

a. Financial skills? b. Marketing and promotion? c. Medical records? d. Information management system? If yes, do you apply the data you collect to better manage your

health business? e. Other (explain)

10. What are your major cost components?

(Probe – labor, drugs, lab tests, other) a. How would you lower cost of the products/services that you provide without compromising the

quality? b. How would you increase the quality of your products/services without increasing the costs?

11. Do you collaborate with the public sector?

(Probe for training, financial aid, supplies, contracting, send data to the public health information system, referral system, other?)

a. How important is the collaboration to the success of your business? b. Do you face any challenges in these collaborations? Which ones? c. How do you think such collaborations can be improved further? d. Do you think the private health sector could serve a portion of those who now rely on the Ministry of

Health for most of their services? e. Would you want to expand to serve such a population? What would it take to expand into this

market? f. From your perspective, how open is the government and/or Ministry of Health to working with the

private sector? g. Are there parts of the market that are attractive/not attractive to you because of the public sector

services? (Probe: maternity, U5s, family planning, diagnostics,)



12. Do you see opportunities to expand your business/service? What do you see as potential areas

for expansion and improvement? a. New markets (geographical, target group) b. New products c. Do you have specific ideas/recommendations/plans?

13. How do you give and receive (health) information? (Probe for channels radio, TV, newsletter, email, brochures, posters, mhealth, ehealth, etc.)

a. How do your clients find out about you? b. What is your most preferred channel of getting/receiving health information?

Do you have any questions about this project or interview?



8 Annex 2: Poverty screening tool

For all questions, please indicate the score by cricking appropriate options provided. If housheold/indiviudal

poorest will score 12 out of posibel 36 Maximum scores. Observe and ask the quetsions.

Domain Indicator Score

Housing Temporary housing made of mud or cardboard/papers 1

Semi permanent housing made of cement mud or wood or iron sheet 2

Permanent house made of brick or stone 3

House space One small room shared with other family 1

Two small rooms not sharing with other people 2

More than two rooms with additional space 3

Rental status Pay rent up to KES 500 1

Pay rent above 500 2

Do not pay rent/own house/shack 3

Source of water

Free, untreated water from river or spring 1

buy water from community tap or well 2

private water tap or well 3

Fuel for cooking Firewood or sawdust /straw/animal dung 1

charcoal or kerosene 2

electricity/gas 3

Security No doors /windows 1

Wooden doors or windows 2

Steel doors or watchmen 3

Garbage collection scattering 1

paper garbage bags 2

paid garbage collection 3

Sanitation bush/flying toilet 1

community pit latrine 2

private pit latrine /flush toilet 3

Daily income of HH

Less than KES 100 Per day 1

100-199 KES Per day 2

200-500 per day 3

average number of meals per day

one meal or less a day 1

more than one but less than three meals a day 2



three meals or more 3

access to health services

home base care/herbal medicine 1

public hospital 2

private hospital /clinic 3

Type of work Daily irregular work (Manual or other) 1

Regular-factory worker/farm worker /small trader 2

business man/Own large business 3

total score



Annex 3: Thematic Framework

Introduction

The thematic framework is presented here is based on an initial immersion of the data from seven sites.

These included in depth interviews as well as focus group discussions (FGDs) with various categories of

actors. The process of data collection was anchored on the broader programme objectives of the Private

Sector Innovation Programmeme for Health (PSP4H) . They include:

> Assessing and defining who are the poor in Kenya and to better understand their provider preferences,

their health-seeking behaviour, and their willingness and ability to pay for certain health services and

products

> Exploring under which circumstances does the private health sector deliver health services and products

to lower income groups, determining if these services and products are of quality and affordable, and

concluding if the private health sector services and products actually reach the poor

> Assessing the Kenyan health market and sub-sectors to identify and pilot appropriate pro-poor

interventions by the private health sector and to conduct action research to establish if the private health

sector can deliver quality, affordable health services that reach the poor

> Sharing the lessons learned from the different pro-poor health market interventions with Kenyan

stakeholders as well as international practitioners in public health working in developing countries

> This study aimed to address mainly objectives 1 and 2 stated above. The main research questions are:

> Who are the poor in Kenya, what is the profile for the poor?


population

> what are the health seeking behaviours of health care consumers within the PSP4H programme’s target

population



services?

The guides were developed with this idea in mind. The focus was on two categories of participants; the

beneficiaries – the demand side (the poor) and the investors – the supply side. The guide was designed to

address the question as to whether it is commercially viable for private-for-profit and informal sector

providers to offer quality, affordable health services and products to poor customers and clients? The

questions focussed on incentives (financial and non-financial) motivate (encourage, facilitate) private-for-

profit and informal providers to, what factors enable private providers (formal and informal) to stay in these

new markets and to expand services/products to the poor customers and clients? Among clients the

focus of the guide was on health care seeking patterns, decision making dynamics at household level, and

cost of services. The guide also focussed on the ability to pay and preferences

> The coding framework therefore utilises two main approaches: inductive approaches where two

researchers independently read through the transcripts and developed a set of themes that emanated

from the responses. The emerging themes were then linked with the guide that was used a priori. The

coding framework was developed from reading the set of interviews from seven sites as indicated in table

1 below. A tentative thematic framework was developed for sharing. The final thematic framework will

be finalize after all data have been coded. This document summarizes the initial set of themes used for

this analysis



Table 3: list of transcripts read to develop the thematic framework Site FGD IDI

Busia 2 FGDs with women under 25 and above 1 FGD with health provides

5 IDIs 2 with pharmacists and 3 with private sector investors

Garissa 1 FGD 4 IDIs;

Isiolo 3 FGDs: 2 with women, 1 with health workers

3 IDIs

Kiambu 1 FGD 3 IDIS

Kisumu 1 FGD 1 IDI

Mombasa 1 FGD

Nyamira 1 FGD 1 IDI



THEMATIC FRAMEWORK 1.0 Common medical problems encountered 1.1 Common illnesses 1.1.1 Type of illnesses 1.1.2 Top diseases 1.1.3 Illnesses that people do not seek care 1.1.4 Preferred cost of care seeking

1.2 Care seeking patterns 1.2.1 Sources of care 1.2.2 Care seeking dynamics 1.2.3 Reasons for choice of care 1.2.4 Decisions making dynamics 1.2.5 Health care expenditure 1.2.6 Reason for not seeking care 1.2.7 services offered for free 1.2.8 sources of medicines

1.3 Challenges of service provision 1.3.1 Supply of products 1.3.2 Side effects of FP methods 1.4 Facility Details

1.4.1 History of facility 1.4.2 Services offered 1.4.3 Marketing strategies 1.4.4 Price determination 1.4.5 Staffing 1.4.6 Financing strategies 1.4.7 Client Load 1.4.8 Characteristics of clients served 1.4.9 Expansion strategies 1.4.10 Cost of services 1.4.11 mode of payment of services 1.4.12 facility upgrade 1.4.13 facility type 1.4.14 process of licensing 1.4.15 skill set needed

1.5 Challenges faced by private sector providers 1.5.1 Financial 1.5.2 Licensures 1.5.3 Low sales 1.5.4 Competition 1.5.5 Staff turn over 1.5.6 Work load 1.5.7 Space 1.5.6 Regulation 1.6 Mechanisms of involving private sector for poor

1.6.1 Subsidies 1.6.2 Waiver 1.6.3 Financial incentives 1.6.4 Non financial incentives 1.7 Qualities of a good health services 1.7.1 Holistic services 1.7.2 Waiting times 1.7.3 Convenience 1.7.4 Availability of supplies



1.7.5 Trained staff 1.7.6 Positive provider behavior 1.7.7 Credit services 1.7.8 Diagnostic services 1.7.9 Environment 2.0 Facilitating factors to use of private sector

2.1 Cost of access 2.2 Inadequate Human resources in public sector 2.3 Long waiting times 2.4 Equipment and supplies 2.5 Specialised diagnostics 2.6 Private provider behaviours 2.7 Geographical location 2.8 Convenience 2.9 corrupt practices in public facilities 2.10 confidentiality

3.0 Role of devolved government 3.1 Divisions in health sector

3.2 County roles

4.0 Linkages between private and public government 4.1 regulations 4.2 Supportive supervision 4.3 Referrals 4.4 Coordination 4.5 stakeholder forums 4.6 specific services 4.7 Provision of supplies 4.8 Training

5.0 Factors influencing increasing quality of services 5.1 Training 5.2 licensing 6.0 Challenges of private sector

6.1 Business orientation 6.2 regulations 6.3 expansion/Space 6.4 unqualified providers 6.5 competition 6.7 Licensure 6.8 price fluctuations 6.9 Type of clients

7.0 Functioning of private sector 7.1 dual practices 7.2 merits and demerits of dual practices 7.3 Flexibility of service provision 7.4 cost containment 7.5 Credit facilities 7.6 opening and closing hours 7.7 Coverage 7.8 Payment of services

8.0 Communication channels 8.1 Print media 8.2 audio/visual media 8.3 workshop/seminars 8.5 T-shirts/caps 8.6 posters



8.7 preferred channels

9.0 Recommendation 9.1 Recommendation for improving collaboration 9.2 Recommendation for improving health care

a formative survey of the private health sector in the...

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